Multifocal IOLs

Multifocal IOLs
Editor
Frank Joseph Goes
Medical Director
Goes Eye Centre, W Klooslaan 6
B2050 Antwerp
Belgium

Honorary Co-Editors
H Burkhard Dick
Professor and Chairman, Director
Centre for Vision Science
Ruhr University Eye Hospital
In der Schornau 23 - 25
44892 Bochum
Germany
I Howard Fine
Clinical Professor of Ophthalmology
Oregon Health and Science University
Chief Consultant
Drs Fine, Hoffman and Packer, LIC
1550 - Oak St, Ste 5, Eugene, OR 97401, USA
Michael C Knorz
Medical Faculty Mannheim of the University of Heidelberg
Professor of Ophthalmology
Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany
Richard L Lindstrom
Adjunct Professor Emeritus, University of Minnesota Dept. of Ophthalmology
Founder and Attending Surgeon, Minnesota Eye Consultants
2811 Westwood Road, Wayzata, Minn. 55301, USA

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Multifocal IOLs
© 2008, Frank Joseph Goes
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form
or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the
editor and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made
to ensure accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent
error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2008

ISBN 978-81-8448-366-6
Typeset at JPBMP typesetting unit
Printed at Ajanta Press
 This book is dedicated
to
my wife Rita who is my guide for the important decisions
in my professional career
— Dr Frank Joseph Goes

It is a great honor to serve as one of the honorary co-editors for this extraordinary book.
Every author brings their extensive experience with multifocal IOLs to their contribution,
making it a definitive work on the subject. With the increasingly important role that
multifocal IOLs play in our practices, I am sure that you will find this book to be an excellent
reference tool on the subject.

— H. Burkhard Dick

This book is dedicated

to
our patients who honour us by entrusting their vision to our surgical care, and who stimulate
us to look for better techniques, technologies, and devices to further enhance our results
— Dr I Howard Fine

This book is dedicated

to
all my teachers who helped me to learn and refine the art of ophthalmic surgery
— Dr Michael C Knorz

I dedicated my small contribution to this book to my wife, Jaci Lindstrom,

for her support and guidance.
— Richard L Lindstrom
 Contributors
Alois K Dexl MD MSc Cyres K Mehta MD MS
Assistant, Prim Univ Mehta International Eye Institute
University Eye Clinic Sea Side, 147 Shahid Bhagat Singh Road
Paracelsus Medical University Salzburg, Austria Colaba, Mumbai 400005, Maharashtra
Universitätsklinikum, St.Johanns-Spital Ph +91 22 22151303
Müllner Hauptstrasse 48 Fax: +91 22 22150433
A 5020 Salzburg e-mail: admin@mehtaeyeinstitute.com
Phone: +43 662 4482 - 5788 website http://www.mehtaeyeinstitute.com
Fax: +43 662 4482 - 3703
e-mail: a.dexl@salk.at David R Hardten MD
Minnesota Eye Consultants
Angel Lopez-Castro MD
Director of Fellowships and Refractive Surgery
Laservision Madrid
710 E. 24th Street, Suite 100
Jose Ortega Y Gasset 56-dupl. Madrid 28006
Minneapolis, MN 55404
Ph: +34914448230
Ph: 612-813-3632
Fax: +34913093289
Fax: 612-813-3658
e-mail: alopez@laservision.es
drhardten@mneye.com
Ashok Garg MS PhD
Garg Eye Institute and Research Centre Ekkehard Fabian Prof. Dr
Chairman and Medical Director AugenCentrum Rosenheim
235, Model Town, Dabra Chowk 83022 Rosenheim/Germany, Bahnhofstrasse 12
Hisar - 125005, (India) Ph: 0049 8031 38950-0
Ph: 9896025180 Fax: 0049 8031 38950-38
91-1662-250305 e-mail: Prof.Fabian@AugenCentrum.de
e-mail: drashok_garg@yahoo.com
Elizabeth A Davis MD FACS
Brad Soper
Frank Joseph Goes
Eyemaginations, Inc.
W Klooslaan 6, B2050 Antwerp, Belgium
600 Washington Avenue, Suite 100
frank@goes.be
Towson, MD 21204, USA
Tel+32.3.2193925
Burkhard H Dick MD Fax +32.3.2196667
Professor and Chairman, Director www.goes.be
Center for Vision Science
GU Auffarth MD
Ruhr University Eye Hospital
Vice-Chairman, Chief Surgeon
In der Schornau 23 - 25, 44892 Bochum
Dept. of Ophthalmology
Germany
University of Heidelberg, INF 400, 69120 Heidelberg
Phone: +49-234-299-3101
Tel.:+49-6221-5636631
Fax: +49-234-299-3109
Fax:+49-6221-561726
burkhard.dick@kk-bochum.de
Head:
Carlos Vergés MD PhD International Vision Correction Research Centre
Professor and Head Department of (IVCRC)
Ophthalmology, CIMA e-mail:ga@uni-hd.de
Universidad Politécnica de Cataluña, Spain www.lasik-hd.de
viii Multifocal IOLs

Günther Grabner Jorge L Alió MD, PhD

Chairman Department of Ophthalmology, Miguel Hernandez
University Eye Clinic University, Elche, Spain.
Paracelsus Medical University Salzburg Vissum Corporation, Spain
Austria Professor and Chairman of Ophthalmology
Universitätsklinikum, St.Johanns-Spital Medical Director
Müllner Hauptstrasse 48, A 5020 Salzburg Avda de Denia s/n, Edificio Vissum, 03016
Phone: +43 663 4482 - 3701 Alicante, Spain
Fax: +43 663 4482 - 3724 Ph: 34 965 15 00 25
e-mail: g.grabner@salk.at Fax: 34 965 15 15 01
e-mail: jlalio@vissum.com
Hakan Kaymak MD
Knappschaft´s Hospital Keiki R Mehta MD MS
Department of Ophthalmology Mehta International Eye Institute
An der Klinik 10, 66280 Sea Side, 147 Shahid Bhagat Singh Road, Colaba
Sulzbach/Saar Mumbai 400005
Germany Maharashtra, India
Ph: 0049(0)6897-5741118 Ph +91 22 22151303
Fax: 0049(0)6897-5742139 Fax: +91 22 22150433
e-mail: sek-augen@kksulzbach.de e-mail: admin@mehtaeyeinstitute.com
website http://www.mehtaeyeinstitute.com
Henk Weeber PhD
AMO Groningen b.v. M Neunzig
van Swietenlaan 5 Ambulante Operationen - Augenklinik
Ph: +31 50 5296674 Belegärzte im Klinikum Rosenheim
Fax: +31 50 5276824 LUITPOLDHAUS
e-mail: henk.weeber@amo-inc.com 83022 Rosenheim
Bahnhofstrasse 12
Howard I Fine MD Ph: 08031-38950-0
Clinical Professor of Ophthalmology Fax: -38950-38
Oregon Health and Science University e-mail: info@AugenCentrum.de
Chief Consultant www.AugenCentrum.de
Drs Fine, Hoffman and Packer, LIC
1550 - Oak St, Ste 5 Magda Rau MD
Eugene, OR 97401 Dayclinic, Privatclinic Dr Rau, Janahof 2, 93713 Cham
USA Eye Department Hospital Cham, Germany
Ph: 541-687-2110 Ph: +49 9971 861076
Fax: 541-484-3883 Fax: +49 9997 34343
e-mail: sherrie@finemd.com
website:www.finemd.com Michael C Knorz MD
Medical Faculty Mannheim of the University of
Joe Boorady Heidelberg
Chief Operating Officer Professor of Ophthalmology
Eyemaginations, Inc. Theodor Kutzer Ufer 1-3, 68167 Mannheim
600 Washington Avenue Germany
Suite 100 Ph: +49 621 383 3410
Towson, MD 21204 Fax: +49 621 383 1984
USA e-mail: knorz@eyes.de
 Contributors ix

Oliver Stachs PhD Thom Terwee

University Eye Clinic Rostock Applied Research
Doberaner Strasse 140, D-18057 Rostock, Germany Advanced Medical Optics Groningen BV
Ph +490381-4948566 Van Swietenlaan 5, 9728 NX Groningen
Fax: +490381-4948502 thom.terwee@amo-inc.com
e-mail: oliver.stachs@med.uni-rostock.de
Uday Devgan MD FACS
Olivier Roche MD Maloney Vision Institute
Hôpital Necker Enfants malades - APHP Chief of Ophthalmology
Service d’ophtalmologie Olive View-UCLA Medical Center
149 rue de Sèvres, F-75013 PARIS 10921 Wilshire Blvd, Suite 900
Ph: + 33 (1) 44 49 45 03 Los Angeles, California 90024, USA
Fax: + 33 (1) 45 65 47 33 Ph: 1-310-208-3937
e-mail: Olivier.roche@nck.aphp.fr Fax: 1-310-208-0169
e-mail: DrDevgan@MaloneyVision.com
Richard L Lindstrom MD
Adjunct Professor Emeritus, University of Minnesota Ulrich Mester MD
Dept. of Ophthalmology Knappschaft’s Hospital
Founder and Attending Surgeon Department of Ophthalmology
Minnesota Eye Consultants An der Klinik 10, 66280, Sulzbach/Saar
2811 Westwood Road, Wayzata, Minn. 55301, USA Germany
Ph: 952-567-6051 Ph: 0049 (0) 6897 5741118
Fax: NR952-567-6182 Fax: 0049 (0) 6897 5742139
e-mail: rllindstrom@mneye.com e-mail:sek-augen@kksulzbach.de

Rudolf F Guthoff Professor MD Werner W Hütz MD

University Eye Clinic Rostock Augenklinik Bad Hersfeld
Doberaner Strasse 140, D-18057 Rostock Klinikum Bad Hersfeld GmbH
Germany 36251 Bad Hersfeld Seilerweg 29, Germany
Ph: +490381-4948501 0049 6621 881468
Fax: +490381-4948502 0049 6621 881477
e-mail: rudolf.guthoff@med.uni-rostock.de e-mail: Werner.huetz@klinikum-hef.de
WWW;KLINIKUM-hef.de
Steven A Koopmans MD,PhD
Department of Ophthalmology, University Medical Wolfgang Haigis MS PhD
Center Groningen, University of Groningen Assistant Professor
POBox 30001, 9700 RB Groningen, The Netherlands University Eye Clinic, Wuerzburg
Ph: +31503612510 11, Josef-Schneiderstrasse
Fax: +31503611709 D-97080 Wuerzburg, Germany
e-mail: s.a.koopmans@ohk.umcg.nl Ph: +49 931 201 20640
Fax: +49 931 201 20454
Theo van Kooten e-mail: w.haigis@augenklinik.uni-wuerzburg.de
Department of Biomedical Engineering
University Medical Center Groningen Zenobia K Mehta OD FAO
University of Groningen, P.O. Box 30001 Mehta International Eye Institute
9700 RB Groningen Sea Side, 147 Shahid Bhagat Singh Road, Colaba
t.g.van.kooten@med.umcg.nl Mumbai - 400005, India
 Foreword
Multifocal IOLs have been in the market since late 1980s, when the first diffractive and refractive IOLs were
introduced. At that time, cataract surgery was mostly performed without capsulorhexis and with ECCE instead
of phacoemulsification. The early multifocals were made from PMMA and required 6-7 mm incisions. The
initial results were promising but there were also a lot of problems—mostly due to these surgical techniques.
Since that time cataract surgery and MIOL implantation have changed dramatically. Cataract surgery had
evolved in a quite safe procedure called refractive lens exchange. The different MIOLs have undergone
extensive research and fine-tuning. All MIOLs are foldable, aspherical and well manufactured. More and
more surgeons implant multifocal IOLs in their patients. Scientific knowledge has been accumulated in that
how to select patients for IOL implantation (see several chapters in this book) and how to calculate the IOLs
(Haigis).
Nowadays, multifocal IOLs are implanted in almost every age group. Several chapters in this book will
be referred to in this regard. Different designs and concepts (diffractive/refractive) are offered by the various
companies. The combination of different MIOLs with different working principles (Mix & Match, Custom/
Match) is at the moment part of the individualization of lens application. Multifocals have clear advantages
over accommodative IOLs. The distant and near focus is fixed and the patient knows what he can expect.
Even individual custom made implants with multifocal and toric components are now available and soon
completely accessible. Multifocals are now really top products with more and more extrafeatures. Patient
selection still remains the main issue for successful result. This book will help the surgeon understand the
different types of MIOL and which MIOL is the best in what situation.
The success of multifocal will not be in danger, as the accommodative IOLs are still not good enough to
provide satisfactory near and distant vision. The editors of this book did a tremendous job to get an up-to-
date overview on multifocals and future development.

GU Auffarth MD
Vice-Chairman, Chief Surgeon
Dept. of Ophthalmology
University of Heidelberg
INF 400
69120 Heidelberg
Tel.:+49-6221-5636631
Fax:+49-6221-561726
Head:
International Vision Correction Research Centre (IVCRC)
E-mail:ga@uni-hd.de
www.lasik-hd.de
 Preface
HOW CAN WE IMPROVE THE REFRACTIVE STATUS OF THE EYE?
The time has come to reconsider the approach of ”How can we improve the Eye” by taking the least amount
of risk and by obtaining the highest degree of patient satisfaction. Since the major refractive component of the
eye is situated in the lens, the latter approach seems to be the most appropriate.

WHY ONLY IN RECENT YEARS AND NOT BEFORE THAT TIME?

Because lens surgery in general and lens refractive surgery in particular has evolved a lot and has improved
tremendously by
1. A more gentle approach for the patient with the introduction of topical anesthesia and outpatient surgery.
2. Reducing the risk of bad outcomes and complications to an absolute minimum since modern phacosurgery
has evolved a lot using small incision surgery and better performing machines.
Patient expectations have also changed. The old approach of restoring eyesight is not sufficient any more
in our spoiled western world. However during my recent trip to Bengaluru at the occasion of AIOS 2008
I learned that 20,000,000 Indian patients are on the waiting list for restoration of their eyesight—we should
not forget that.
Our patients don’t want to loose physical capacities; they go on practising fitness till very old age, they
follow nutritious diets, etc. The same thing happens with their visual function and with their accommodation
at 70 years they want to see as good as they are 20 years old.

HOW ABOUT PHACO-ERSATZ?

We are not yet there, as will be discussed later on by Prof Guthoff and his group. At occasion of my first
phacocourse in Geneva 20 years ago, Jean Marie Parel discussed Phaco Ersatz. Since then not much progress
has been made resulting in the real accommodative lens is not yet available and will probably not come out
before 5-10 years from now.
However much has changed inbetween and our present multifocal lenses have improved a lot. We are
able to improve the lifestyle of our patients in an important way on condition that we use the right personalized
approach for the right patient. It is our duty to bring the good and the bad news, to have an honest discussion
with our patient and then to decide together with them, taking into consideration their wishes and the refractive
condition of their eye.

NEW MULTIFOCAL IOLs

With the continuing improvement of surgical techniques along with the technical refinement of second-
generation multifocal intraocular lenses (MIOL), refractive lens exchange (RLE) is becoming increasingly
popular since it is an easy procedure and addresses both the aspects of a patient’s refractive errors and
presbyopia. This approach is particularly attractive for eyes that are not suitable for corneal refractive surgery
and in whom early peripheral lens opacities are present. However, there are some restrictions to this approach
since some patients may have unrealistic expectations that cannot be met. The good candidates for the
implantation of MIOLs are those with an open-minded and flexible personality who understand the need for
postoperative visual adaptation, the eventual presence of unwanted optic effects such as halos and glare and
the eventual need for laser enhancement afterwards.
xiv Multifocal IOLs

New intraocular lenses that might advocate the increasing interest in RLE include the diffractive Tecnis
ZM900 (Advances Medical Optics, AMO, Santa Ana, CA), the refractive ReZoom (AMO) and the apodized
diffractive AcrySof ReStor (Alcon laboratories, Ft. Worth, TX). Recent clinical data have shown that with
careful patient selection and accurate biometry these three MIOLs provide excellent functional vision 1-7 with
less photic phenomena, less dependence on glasses and higher patient satisfaction than first generation MIOLs.
However, each MIOL technology is unique and the patient’s needs and lifestyle should be taken into
consideration when making a surgical decision.
I realize that the book will be far from complete or perfect since we all are humans and not God. I did what
I could. We wanted to bring a diversified approach of this subject and included—patient selection,
surgery complications, new lenses, future technologies, physical principles, etc.—different approaches. The
deadline—which has changed several times—prevented us to include only two chapters.
We thank all the contributing authors and their staff and are convinced that all chapters have their intrinsic
value.
I thank also my international colleagues for their support and for having accepted the honorary
co-authorship for this book.
I thank also M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for the excellent job done. There
was no sponsor of this book.
I dedicate this book to my wife and my four grandchildren-Stéphanie-William-Louise-Vincent.

REFERENCES
1. Lane SS, Morris M, Nordan L, Packer M, Tarantino N, Wallace RB 3rd. Multifocal intraocular lenses. Ophthalmol Clin
North Am 2006;19:89-105.
2. Hütz WW, Eckhardt HB, Rohrig B, Grolmus R. Reading ability with 3 multifocal intraocular lens models. J Cataract
Refract Surg 2006;32:2015-21.
3. Kohnen T, Allen D, Boureau C, Dublineau P, Hartmann C, Mehdorn E, Rozot P, Tassinari G. European multicenter study
of the AcrySof ReSTOR apodized diffractive intraocular lens. Ophthalmology 2006;113:584.e1.
4. Blaylock JF, Si Z, Vickers C. Visual and refractive status at different focal distances after implantation of the ReSTOR
multifocal intraocular lens. J Cataract Refract Surg 2006;32:1464-73.
5. Chiam PJ, Chan JH, Aggarwal RK, Kasaby S. ReSTOR intraocular lens implantation in cataract surgery: quality of vision.
J Cataract Refract Surg 2006 ;32:1459-1463. Erratum in: J Cataract Refract Surg 2006;32:1987.
6. Sallet G. Refractive outcome after bilateral implantation of an apodized diffractive intraocular lens. Bull Soc Belge
Ophtalmol 2006;299:67-73.
7. Souza CE, Muccioli C, Soriano ES, Chalita MR, Oliveira F, Freitas LL, Meire LP, Tamaki C, Belfort R Jr. Visual performance
of AcrySof ReSTOR apodized diffractive IOL: a prospective comparative trial. Am J Ophthalmol 2006;141:827-32.

Frank Joseph Goes

 Contents
SECTION ONE: BASICS
1. Optical Principles of Multifocal IOLs ............................................................................................................. 3
Henk Weeber
2. Accommodative Lens Refilling ...................................................................................................................... 12
Steven A Koopmans, Thom Terwee, Theo van Kooten
3. How to Test Reading Improvement after Presbyopic Surgery? ............................................................... 18
Alois K Dexl, Günther Grabner
4. Importance of Reading Speed in Multifocal IOL Implantation .............................................................. 28
Werner W Hütz
5. Multifocal IOLs and Dynamic Vision ........................................................................................................... 38
Carlos Vergés
6. Improvement of Visual Function with Training after Multifocal Intraocular Lens Implantation ... 47
Hakan Kaymak, Ulrich Mester

SECTION TWO: HOW TO BRING THE CONCEPT TO THE PATIENT?

7. Eyemaginations .................................................................................................................................................. 57
Joe Boorady, Brad Soper

SECTION THREE: MULTIFOCAL AND ACCOMMODATIVE IOLs/OVERVIEW

8. The Current Status of Multifocal IOLs ......................................................................................................... 65
H Burkhard Dick
9. Current Status of Accommodative IOLs ....................................................................................................... 75
I Howard Fine, Richard S Hoffman, Mark Packer
10. Clinical Results with the New Generation of Multifocal Intraocular Lenses ....................................... 84
Ulrich Mester, Hakan Kaymak

SECTION FOUR: IOL POWER CALCULATION FOR MULTIFOCAL IOLs

11. IOL Calculation for Multifocal IOLs ............................................................................................................. 93
Wolfgang Haigis
12. IOL Power Calculation Formulas—An Update ......................................................................................... 100
Ashok Garg

SECTION FIVE: PATIENT SELECTION

13. Premium Presbyopia—Correcting IOLs ..................................................................................................... 115
Uday Devgan
14. Mixing and Matching IOLs: Options and Results .................................................................................... 126
Elizabeth A Davis, Richard L Lindstrom
xvi Multifocal IOLs

SECTION SIX: CLINICAL EXPERIENCE WITH DIFFERENT MULTIFOCAL IOLs

15. Personal Experiences with the Single Optic 1 CU and the
Synchrony Dual Optic Accommodative IOLs ........................................................................................... 133
GU Auffarth
16. First Experiences with the Rayner Aspheric, Toric, Multifocal Intraocular Lens (M-Flex-T) .......... 138
GU Auffarth
17. Bilateral ReZoom Implantations: Personal Experience ........................................................................... 141
David R Hardten, Parag D Parekh, Mona Fahmy
18. Multifocal IOLs in Children .......................................................................................................................... 147
Keiki R Mehta, Cyres K Mehta, Zenobia K Mehta
19. How to Proceed with Multifocals in Children? ......................................................................................... 156
Roche Olivier

SECTION SEVEN: CUSTOMIZING MULTIFOCAL IOLs

20. Male/Female Differences Regarding Patient Satisfaction after
Implantation of Multifocal IOLs .................................................................................................................. 165
M Rau
21. Mixing and Matching Customized Approach Tecnis-ReZoom .............................................................. 171
Angel Lopez-Castro
22. How to Obtain Patient Satisfaction Using ReZoom-Tecnis and Tecnis-Tecnis? ................................ 183
Frank Joseph Goes

SECTION EIGHT: SURGICAL FINESSES

23. AcriLISA with MICS ....................................................................................................................................... 201
Jorge L Alió, Bassam EI Kady, Pawel Klonowski
24. State of the Art Surgery for Multifocal IOL Implantation ...................................................................... 210
E Fabian, G Kneib, M Neunzig,U Seher, V Sipp, R Brandl
25. Laser Enhancement after Multifocal IOL Implantation .......................................................................... 215
Michael C Knorz

SECTION NINE: FUTURE

26. Phaco-Ersatz: Will it be there Tomorrow? .................................................................................................. 221
Oliver Stachs, Rudolf F Guthoff

Index .................................................................................................................................................................... 233

 Optical Principles of Multifocal IOLs 3

1
Optical Principles of
Multifocal IOLs

Henk Weeber

SUMMARY measurements can demonstrate the differences in

optical performance of different designs.
Multifocal lenses are generally either refractive or
diffractive. Refractive and diffractive multifocal lenses INTRODUCTION
are based on entirely different optical principles.
Multifocal lenses are generally either refractive or
The optics of a refractive multifocal lens are based
diffractive. 1-4 Although other principles, notably
on the refraction of light at the surfaces of the lens
birefringe,5 have been proposed, so far, none have
optic, obeying Snell’s law of refraction. The lenses
progressed beyond the conceptual stage to
consist of concentric zones of which each has a
commercial production. Refractive and diffractive
different power. In principle, their performance
multifocal lenses are based on entirely different
depends on pupil size and centration of the lens;
optical principles (refraction, the change in direction
however, this can be reduced by increasing the
of light rays as they travel through clear mediums of
number of zones and by aspherizing the zone
different densities; and diffraction, the bending,
transitions.
spreading and interference of light when it passes an
The optics of diffractive MIOLs are based on the
obstacle). Thus the lenses have different optical
constructive and destructive interference of light. The
characteristics. Some of these differences have
lenses generate two main focal points in which the
clinical relevance. Nevertheless, both refractive and
majority of the incoming light is focused. Diffractive
diffractive multifocal lenses have evolved into state
MIOLs can be designed to be totally independent of
of the art designs, resulting in satisfactory clinical
pupil size. Also, diffractive MIOLs exhibit a favorable
results with both types, without one being conclu-
chromatic behavior, essentially correcting the eye’s
sively better than the other.
chromatic aberration in the near focus. This can result
This chapter discusses the optical principles of
in superior visual performance for near, without
refractive and diffractive multifocal IOLs, and shows
compromising far vision.
how the difference in optical principle results into
Refractive and diffractive multifocal lenses have
differences in optical performance. It is also shown
different optical characteristics. Testing the optical
how the optical performance can be measured on an
performance of IOLs on an optical bench gives an
optical bench.
indication of their clinical performance. Light
distribution and image quality can be measured both
OPTICAL PRINCIPLES OF REFRACTIVE MIOLs
subjectively and objectively. The use of realistic eye
models is crucial for the correct interpretation of the The optics of a refractive multifocal lens are based
results, however, when this is taken care of, these on the refraction of light at the surfaces of the lens
4 Multifocal IOLs

optic. Light changes velocity as it travels from one

optical medium to another, resulting in a change in
direction of the light, obeying Snell’s law of
refraction.
The basic working principle of refractive
multifocal lenses can be demonstrated by following
light rays traveling through the lens. Figure 1 shows
the basic principle of a two-zone “bull’s eye”
refractive bifocal lens. The lens has a central concen-
tric zone refracting the incoming light from near
objects towards the retina, and a peripheral
concentric zone refracting the light of distant objects
towards the retina. A major disadvantage of this
basic design is the fact that pupil size and decen-
tration of the lens and/or pupil affect the optical
behavior of the lens. To reduce the pupil dependent
behavior of refractive multifocal IOLs, more
concentric zones can be included. In conjunction with
the addition of more zones, the center zone is usually
designated for distance vision (Fig. 2). In addition
to adding zones, the zone transition can be made
aspherical. The design elements can be combined in
lenses having multiple aspherical zones, where the
zone transitions are also aspherical. This design has
Figs 3A and B: (A) Ray tracing of a multifocal IOL with multiple
been implemented in the widely used ArrayTM and
aspheric zones. (B) “Add power plot” of a multifocal IOL with
ReZoom TM (both AMO, Santa Ana, CA, USA) multiple aspheric zones. The horizontal axis shows the
multifocal lenses. Because of their aspheric zones and position on the IOL surface (aperture), while the vertical axis
zone transitions, these lenses also provide improved shows the local add power. The add power then is a measure
image quality for objects at intermediate distances of the object distance that is in focus
(Fig. 3A). With the introduction of the aspheric zones
the optical axis. The specification for these surfaces
and transitions, these designs have become
can be described with an “add power plot”, as shown
increasingly complex, where each part of the lens
in Figure 3B. The horizontal axis shows the position
surface directs the light to an individual location on
on the IOL surface (aperture), while the vertical axis
shows the local add power.

OPTICAL PRINCIPLES OF DIFFRACTIVE MIOLs

Fig. 1: Ray tracing of a basic refractive bifocal IOL
Fig. 2: Development of refractive multifocal lenses
Diffraction of light refers to the bending and
spreading of waves passing by an obstacle. However,
the most important optical phenomenon used to
achieve multifocality with diffractive lenses is light
interference. The diffractive optics of MIOLs are based
on the constructive and destructive interference of
light.
A classic experiment that demonstrates the effects
of diffraction and interference is that of a wavefront
passing through two slits (Fig. 4). When the slits are
each narrow compared to the wavelength of the light,

Fig. 4: Double-slit experiment, demonstrating diffraction when
the light passes the slits and causes constructive and
destructive interference
they produce an interference pattern behind the slits.
When the light passes the slits, it bends around their
corners and produces two diverging spherical
wavefronts. At specific points in space (see blue
points in Figure 4), the waves from the two slits
show constructive interference. At other points (not
shown in the diagram) the light waves from the two
slits cancel each other out completely (destructive
interference), resulting in dark areas. By placing a
projection screen at some distance behind the slits,
lines of constructive interference show as a regular
pattern of bright lines.
The diffractive multifocal lens does not have the
appearance of a number of slits; however, it is
analogous in that it does generate a set of wavefronts
as light passes through the lens, as shown in
Figure 5. Each zone (echelette) in the diffractive lens
profile generates an annular wavefront, and the
interaction of these wavefronts causes constructive
interference at specific points in space. These are the
focal points of the lens. As in the double-slit example,
a diffractive lens has an infinite number of focal
points, and the brightness is different for each. The
sum of the light energy in all focal points reflects the
total amount of light that enters the lens. A bifocal
diffractive lens has two focal points that are relevant
for vision- the far and near foci. The lens design causes
these two points in space to receive the majority of
the light energy. However, even in the best optimized
diffractive MIOL, it is impossible to completely
eliminate other, nonfunctional focal points. Figure 6
Optical Principles of Multifocal IOLs 5
Fig. 5: Wavefront passing a plano diffractive lens
shows the light distribution of the foci in mono-
chromatic light for two MIOLs. The graph on the
left shows the distribution when the lens has equal
amounts of energy in the far and the near focus,
and the graph on the right shows the distribution
for a distant-dominant lens design. The non-imaging
foci are about 10 times less bright than the primary
foci. A loss of up to 19% of the light to higher order
foci may seem a large amount, but it has not been
problematic clinically.
Each zone of the diffractive lens splits the light
to both foci—a fundamental difference from
refractive multifocal lenses. Figure 7 shows how light
is focused in each type of lens. The diffractive lens
generates two overlaying bundles of light, with both
covering the full aperture. One focuses in the near
and the other in the distance. The refractive lens
generates multiple bundles of light, and each bundle
originates from a specific part of the aperture.
One of the special properties of diffractive lenses
is their chromatic behavior. The cornea as well as the
natural lens induces chromatic aberration. Ocular
chromatic aberration occurs because the refractive
indices of the ocular tissues (cornea, aqueous,
vitreous, and lens) vary with wavelength, causing the
power of the eye to be different for different
wavelengths and leading to a chromatic difference in
refraction (the eye is hyperopic for red light and
myopic for blue light). The refractive index decreases
with longer wavelengths. Diffractive lenses also
exhibit chromatic aberration; however, their
chromatic aberration is the reverse of the eye tissues
6 Multifocal IOLs

Fig. 6: Light distribution from two diffractive multifocal lenses in monochromatic light. (A) Diffractive lens with a 50/50 split
between the far and near focus. The total light in the far and near equals 81% of the incoming light. (B) Far-dominant
diffractive lens with 70/30 split between far and near. The light in the far and near equals 83% of the incoming light

Figs 7A and B: Demonstration of the light-focusing characteristics of diffractive and refractive multifocal lenses. (A) overview
of the light passing through a diffractive multifocal lens. The lens (see the left edge of the picture) is positioned in a water
bath. The light from all zones in the lens is split between the two focal points. (B) Focal area of light passing through a
refractive multifocal lens. The different zones in the lens optic (not shown) direct bundles of light to different focal points. In
addition, the light passing aspherical zones and aspherical zone transitions converts to intermediate foci

in that diffractive lenses have a higher power for
longer wavelengths. Therefore, a diffractive lens is
able to correct the chromatic aberration of the eye.
Considering the chromatic aberration of the
diffractive multifocal lens, the 0th order (far) focus of
the lens acts like a normal refractive lens, so the far
focus has the same chromatic aberration as that of a
refractive IOL. The 1st order (near) focus has negative
chromatic aberration and partially corrects for the
chromatic aberration of the cornea. As a result, the
image quality of the near focus is relatively high
compared to that of a refractive MIOL having the
same light distribution.
TESTING OPTICAL PERFORMANCE
ON AN OPTICAL BENCH
Testing the optical performance of IOLs on an optical
bench gives an indication of their clinical
performance.6-11 Accordingly, the ISO standard for
IOLs includes requirements for optical performance
under laboratory conditions. Optical properties to
be considered for multifocal designs are the
distribution of light among the different foci, the
modulation transfer function (MTF), and the
appearance of halos.
Whereas the light distribution of refractive
multifocal lenses is determined by the areas of the
 Optical Principles of Multifocal IOLs 7

concentric zones, the light distribution of diffractive
multifocal lenses is determined by the height of the
diffractive profile-an independent parameter that
can be varied with pupil size or the size of the
concentric zones.
Pieh et al 12 tested the light distribution of
multifocal lenses on an optical bench using a white
light source and a 4.5 mm aperture. According to
these measurements, the diffractive multifocal model
811E (Pharmacia) distributes most of the light to the
near focus (relative far versus near was 42% versus
58%). Another study by Ravalico et al,13 which was
also done on an optical bench and in monochromatic
light, concluded that the lens was slightly far
dominant (relative far versus near was 55% versus
45%). The difference in outcome between these two
studies shows that measurements of the light
distribution of diffractive lenses can be difficult to
interpret, because the measurement outcome is
sensitive to the test parameters. The test parameters
are not always reported in enough detail to explain
these differences.
Because the behavior of diffractive lenses in air
is completely different from their behavior in water,
all measurements should be carried out in a water
cell. Even the precise refractive index of the water
influences behavior. To simulate in vivo conditions
the refractive index of pure water in the laboratory
should be slightly increased when measuring
diffractive IOLs. In addition, wavelength plays an
important role. For white light, the specific spectral
intensity of the light source and the spectral
sensitivity of the detector can significantly impact
test results.
Although light distribution is a meaningful
characteristic of the optical behavior of a multifocal
lens, the quality of the images produced by the lens
in its respective foci is more important. Image quality
can be measured in several different ways. One
subjective method for assessing image quality is a
look-through model eye. Such a system can be
equipped with an ocular lens for direct viewing14,15
or with a camera for taking photographs. 16-19
Figure 8 shows images taken by Gobbi and co-
workers17 of 5 multifocal IOL models. The images
were taken at fixed distances of 6 m and 40 cm from
a monitor showing an ETDRS optotype chart. As
not all lenses have the same add power, the fixed
distance of 40 cm may not be the optimal reading
distance for all lens models. Nevertheless, the test
is useful for demonstrating the image quality of the
respective lenses.
A further improvement in this testing method is
the application of an artificial cornea with the
spherical aberration of an average human cornea.
Tests with such an eye model using the image of US
Air Force Target Projections reported by Hütz and
co-workers20 are shown in Figure 9.
An established objective and quantitative
measure of the image quality of an IOL is the
modulation transfer function (MTF),12, 21,22 which
describes the ratio between the contrast in the image
versus the contrast of the viewed object. An MTF
curve usually shows the modulation at a range of

Fig. 8: Images of an ETDRS optotype chart taken with the 5 multifocal IOL models and 1 monofocal IOL with a 5.0 mm pupil.
The left side of each photograph shows the chart at 6 m, and the right side shows a minified replica on paper at 40 cm. The top
line visible in all pictures (showing the letters C, D, and H) corresponds to 0.8 logMAR (20/125). In the AT733 photograph, the
black broken circle corresponds to the equivalent size of the foveola (1 degree z 300.0 mm) and the solid white circle corresponds
to the fovea edge (5 degrees z 1.5 mm), where visual acuity is estimated to be about 50%and 25% of the center value,
respectively. Ghost images are clearly seen, especially in the peripheral visual field (AT737 Z Acri.Twin 737D; AT733 Z Acri.Twin
733D). (Gobbi et al 200717, reprinted with permission from Elsevier)
8 Multifocal IOLs

Figs 9A and B: US Air Force Target Projections photographed through 2 diffractive multifocal lenses.
(A) Focused at far vision, (B) Focused at near vision (Hütz 200620, reprinted with permission from Elsevier)

spatial frequencies (the spatial frequency is the

inverse of the object size). Also the ISO standard
prescribes MTF measurements for multifocal lenses
(ISO 11979-9). To produce relevant results, these
measurements are preferably done in an eye model23
with the lens immersed in water. To properly judge
the results, one must recognize that the ISO eye
model was developed for measurements of spherical
lenses.24 It has been shown that measurement values
may vary depending on the eye model and that even
the ranking order of different IOL designs in a test
series can change when different eye models are
being used.25,26 A good representation of the in vivo
Fig. 10: Typical MTFs of a monofocal and multifocal lens,
image quality of lenses can be obtained if the eye as measured in an eye model
model has the same spherical aberration as the
average human cornea. And, for measurements in
white light, the same chromatic aberration as the other hand, the difference in modulation between
average human eye. 16,25,26 The MTF curves in multifocal and monofocal at lower spatial frequencies
Figure 10 were obtained using such an eye model.25 explains why contrast sensitivity tests usually detect
The Figure 10 shows the MTF of a typical multifocal a significant difference between multifocal lenses and
lens as well as that of a monofocal lens. The reduced monofocal lenses.
modulation, typical of multifocal lenses is apparent Depending on the multifocal design, MTF may
at the lower spatial frequencies. At the higher spatial vary with pupil size and light distribution. Light
frequencies, the difference between multifocal and distribution can influence image quality, but the two
monofocal lenses decreases, which explains the are not necessarily proportional. Figure 11 show two
limited difference in visual acuity between monofocal different diffractive multifocal lens designs with
and multifocal patients, since visual acuity measures different relationships of light distribution and image
the maximum detectable spatial frequency. On the quality.
 Optical Principles of Multifocal IOLs 9

In addition to light distribution, the image quality
of a multifocal lens is determined by optical aberra-
tions including spherical aberration, chromatic
aberration, and specific aberrations arising from their
design and manufacture. The spherical aberration
produced by spherical lenses can be avoided by using
an aspheric surface on the IOL. Correction of the
spherical aberration of the average human cornea
has shown to be very successful with monofocal
lenses.27-31 Correction of corneal spherical aberration
is also an expected visual benefit of multifocal lenses.
The latter is indicated by comparing the image quality
of current spherical and aspherical multifocal lenses
as shown in Figure 11. The diffractive multifocal lens
shown in the bottom-left graph has an aspheric
anterior surface that corrects corneal spherical
aberration. The apodized diffractive multifocal lens
shown in the bottom-right picture has spherical
surfaces. Despite the fact that, with larger pupil sizes,
the apodized multifocal lens is highly far dominant,
the image quality is reduced compared to the
aspherical diffractive multifocal lens.
Another optical characteristic of multifocal IOLs
is the appearance, size, and intensity of halos. The
size of the halo depends on (among other things) pupil
diameter and on the add power of the lens. As a
general rule, the halo grows larger with larger pupils32
and higher add powers; however, specific aspects
of a design can alter this outcome. For example, a
multifocal lens in which the peripheral area is
designed to direct 100% of the light to the distance
focus does not increase halo size for large pupils

Fig. 11: Light distribution (top) and image quality (bottom) of 2 diffractive multifocal lenses. Left: Aspherical diffractive
multifocal model ZMA00 (AMO). Right: Apodized diffractive multifocal SA60D3 (Alcon)
10 Multifocal IOLs
Fig. 12: Point spread functions demonstrating different
types of halos
viewing at a distance, which can be helpful for night
driving, but, such a design reduces near vision for
patients with large pupils.
The intensity profile of halos can vary with
different multifocal lenses, depending on light
distribution and design specifics. For example,
diffractive multifocal lenses can have a halo
resembling a filled circular area of equal intensity,
but zonal refractive lenses can have a halo like an open
ring (Fig. 12). Halos can be recorded in an eye
model,12,13,17 but interpretation of the obtained images
is difficult. In addition, the recorded image may
differ from the in vivo retinal image 33-35 due to
corneal aberrations like astigmatism and higher
order aberrations. The ultimate measure of halos is
the degree to which they are bothersome to the
patient. The halo effect presents itself mainly when
there is a bright light in a dark environment (e.g.
night driving). During daytime light levels, the
phenomenon is very weak, which can also be derived
from Figure 8 where halos are present but are barely
noticeable.
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3. Avitabile T, Marano F. Multifocal intraocular lenses. Curr
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4. Pearce JL. Multifocal intraocular lenses. Curr Opin
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5. Fiala W. Birefringent multifocal lenses: Theory and
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6. Knorz MC, Bedoya JH, Hsia TC, Neubert WJ, Jones M,
McCary BD, et al. Comparison of modulation transfer
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8. Lang A, Portney V. Interpreting multifocal intraocular
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9. Eisenmann D, Hessemer V, Manzke B, Stork W, Jacobi
KW. Modulation transfer function and contrast
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Ophthalmologe 1993;90:343-7.
10. Piers PA, Norrby NE, Mester U. Eye models for the
prediction of contrast vision in patients with new
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11. Peli E, Lang A. Appearance of images through a multifocal
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2001;18:302-9.
12. Pieh S, Marvan P, Lackner B, Hanselmayer G,
Schmidinger G, Leitgeb R, et al. Quantitative performance
of bifocal and multifocal intraocular lenses in a model
eye: point spread function in multifocal intraocular lenses.
Arch Ophthalmol 2002;120:23-8.
13. Ravalico G, Parentin F, Sirotti P, Baccara F. Analysis of
light energy distribution by multifocal intraocular lenses
through an experimental optical model. J Cataract Refract
Surg 1998;24:647-52.
14. Jacobi KW, Reiner J. “Physical eyes” for evaluating
various intraocular lenses for monocular and binocular
use. Klin Monatsbl Augenheilkd 1993;203:433-5.
15. Jacobi FK, Kessler W, Held S. Optical performance of
multifocal intraocular lenses: Investigation of the Array(R)
SA40N vs. Acri.Twin(R) at the “physical eye” according
to Reiner and Jacobi. Ophthalmologe 2007.
16. Gobbi PG, Fasce F, Bozza S, Brancato R. Optomechanical
eye model with imaging capabilities for objective
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2006;32:643-51.
17. Gobbi PG, Fasce F, Bozza S, Calori G, Brancato R. Far
and near visual acuity with multifocal intraocular lenses
in an optomechanical eye model with imaging capability.
J Cataract Refract Surg 2007;33:1082-94.
18. Negishi K, Ohnuma K, Ikeda T, Noda T. Visual simulation
of retinal images through a decentered monofocal and a
refractive multifocal intraocular lens. Jpn J Ophthalmol
2005;49:281-6.

19. Zisser HC, Guyton DL. Photographic simulation of image
quality through bifocal intraocular lenses. Am J
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20. Hutz WW, Eckhardt HB, Rohrig B, Grolmus R. Reading
ability with 3 multifocal intraocular lens models. J
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Sun R, Oksman HC. Optical performance of multifocal
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22. Kawamorita T, Uozato H. Modulation transfer function
and pupil size in multifocal and monofocal intraocular
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23. Norrby NES. Standardized methods for assessing the
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24. Norrby S. Imaging quality of intraocular lenses. J
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26. Norrby NE, Piers P, Campbell C, van der Mooren M.
Model Eyes for Evaluation of Intraocular Lenses. Applied
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27. Denoyer A, Le Lez ML, Majzoub S, Pisella PJ. Quality of
vision after cataract surgery after Tecnis Z9000
intraocular lens implantation: effect of contrast
sensitivity and wavefront aberration improvements on
the quality of daily vision. J Cataract Refract Surg
2007;33:210-16.
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Norrby NE. A new intraocular lens design to reduce
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31. Chen WR, Ye HH, Qian YY, Yang WH, Lin ZH.
Comparison of higher-order aberrations and contrast
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32. Pieh S, Lackner B, Hanselmayer G, Zohrer R, Sticker M,
Weghaupt H, Fercher A, Skorpik C. Halo size under
distance and near conditions in refractive multifocal
intraocular lenses. Br J Ophthalmol 2001;85:816-21.
33. Artal A, Marcos S. Through focus image quality of eyes
implanted with monofocal and multifocal intraocular
lenses. Optical Eng 1995;34:772-9.
34. Hunkeler JD, Coffman TM, Paugh J, Lang A, Smith P,
Tarantino N. Characterization of visual phenomena with
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 2
Accommodative
Lens Refilling
Steven A Koopmans, Thom Terwee, Theo van Kooten
ABSTRACT
Hardening of the lens nucleus and cortex is believed
by many scientists to be the cause of presbyopia.
Replacement of the hardened lens substance by a
suitable soft and transparent polymer offers the
possibility to restore lost accommodation. The first
experiments to replace the lens substance with a soft
refilling material started in 1964. Recently, a new
lens refilling material was developed at AMO.
Experiments with this material in human cadaver
eyes with a lens stretching device to simulate
accommodative changes and experiments in
adolescent rhesus monkeys are described. The
development of capsular opacification after
implantation in rhesus monkey eyes caused a
decrease in optical quality and a decrease of
accommodative amplitude.
INTRODUCTION
Several structures in the human eye contribute to
the process of accommodation. Accommodation
begins with ciliary muscle contraction that releases
the circumferential tension on the zonules keeping
the lens in suspension. The elasticity of the lens
capsule and the lens nucleus and cortex enable the
lens curvatures to increase. During disaccommo-
dation the tension of the zonular fibres, which insert
into the ciliary body and choroid, increases, thus
pulling the lens back into its disaccommodated,
flattened state 1. All of the structures involved in
accommodation (lens capsule 2, lens nucleus and
cortex3, zonula, ciliary muscle,4 choroid)5 show age-
related changes that may explain the onset of
presbyopia at the approximate age of 45 years.
However, many investigators consider hardening
of the lens nucleus and cortex to be an important
factor.3,6,7 It seems to provide a logical explanation
of presbyopia, because the lens changes its shape
during accommodation. If hardening of the lens
nucleus and cortex is responsible for presbyopia,
replacement of the hardened lens substance by a
suitable soft transparent polymer may restore the
accommodative range. Such a replacement is
certainly conceivable in combination with cataract
surgery. Several investigators have refilled the lens
capsule with a lens replacement substance in animal
eyes. Already in 1964, Kessler8 experimented with
lens refilling in cadaver and rabbit eyes with several
materials, but he favoured a room temperature
curing silicone. Through a 2 mm incision at the pars
planar, he removed the lens in small pieces by cutting
it with wire loops and removing them with a small
spoon. To prevent leaking of the refilling material,
he also designed and used several types of plugs to
close the opening in the lens capsule. Due to the low
refractive index of 1.40 of the refill material, the eyes
with the refilled lenses had a hyperopic refraction.
In a study in rabbits, Kessler 9 reported that the
refilled capsules remained clear for two years.
In 1967, Agarwal and co-workers10 also experi-
mented with a silicone lens refilling material. They
could measure the refraction of refilled lenses in
rabbits, but when they performed similar
experiments in monkeys11, the anterior chamber of
the animals became cloudy due to inflammation and

a rapid onset of capsular opacification, despite a
treatment with corticosteroids.
In 1986, the group of Parel and co-workers 12
studied a lens refilling procedure which they named
“Phaco-Ersatz”. They used a highly viscous, procured
silicone refilling material, which stayed in the capsular
bag by cohesion, so they did not need a plug to seal
the capsular bag. The technique was evaluated in
human cadaver eyes and in vivo in rabbit and cat
eyes. Later13, owl-monkeys were used and in these
animals they demonstrated accommodation by
measuring a decrease in anterior chamber depth with
a scan, ultrasound and optical pachymetry in
response to a drop of pilocarpine. Incidentally,
refraction measurements were possible in the
monkeys, but in most animals postoperative
inflammation, followed by capsular opacification,
prevented refraction measurements. One monkey,
aged 17 years, demonstrated a decrease of the
anterior chamber depth for 4 years after surgery.
Together with the vision co-operative research
centre in Sydney, Australia, Parel and co-workers
resumed work on the Phaco-Ersatz lens in 2000.
Dr. Nishi and co-workers14 from Japan have also
studied many aspects of lens refilling. Initially, Nishi
used an endocapsular balloon that was placed in the
capsular bag and subsequently filled with silicone
oil through a filling tube connected to the balloon.
To prevent leaking of the silicone material after
refilling, the tube was occluded with a cured silicone
polymer and cut. With this technique they achieved
accommodation in rhesus monkeys that was
measurable with a refractometer for 6 to12 months.
Because of the technical complexity of the surgical
procedure, they abandoned the technique using an
intracapsular balloon. When Nishi and Nishi 15
performed monkey experiments without the use of
an endocapsular balloon and closed the capsulorhexis
with a capsular plug, refraction could only be
measured one week after surgery. After this,
refraction measurements were impossible due to
capsular opacification.
One particular finding of Dr. Nishi was that
maximum accommodation occurred when the
capsular bag was refilled to two third of its original
volume. This finding was done in experiments with
pig eyes.16 He also used this amount of refill in his
primate studies.
Accommodative Lens Refilling 13
Since capsular opacification occurred and
prevented accommodation and refraction measure-
ments in monkeys, Dr. Nishi shifted his attention to
studies aiming for the prevention of capsular
opacification. However, today he is again designing
a new prototype of an accommodating lens consisting
of a combination of two lens optics and refilling of
the capsular bag in between.
A NEW LENS REFILLING MATERIAL
At AMO Groningen, the Netherlands, a new lens
refilling material was developed recently. It consists
of a two component silicone based polymer that,
after mixing, cures into a network at eye tempe-
rature. The material has a refractive index of 1.42, a
specific gravity of 0.98 and a Young’s modulus of
0.8 kPa after polymerizing for 70 minutes at 20 oC.
The refractive index of the material can be varied
within a wide range so various degrees of ametropia
can be corrected with this refilling material.
Experiments using different models of accommo-
dation were performed with this material.
LENS STRETCHING STUDY
Initially, human donor eyes obtained from a
corneabank were used.17 These eyes are supplied
without a cornea because it has been removed for
transplantation purposes. Under the surgical
microscope the iris was cut away with scissors to
visualize the whole anterior lens capsule. The capsule
was punctured with a sharp needle and with forceps
a 1-1.5 mm capsulorhexis was made in the periphery
of the lens. Through this small opening, the lens
substance was aspirated by suction through a 20G
blunt cannula. Depending on the amount of cataract,
this took more or less time. No ultrasound
emulsification was used as this resulted in frequent
tearing of the lens capsule. When the lens had been
extracted, a silicone plug was inserted through the
opening in the capsule. The silicone plug consists of
a small circular membrane with a suture attached to
it. The suture was used to manipulate the plug into
its proper position to seal the capsulorhexis. The
mixed lens refilling material was injected through a
blunt 25 G cannula which was inserted in the capsular
bag through the capsular opening. After completely
filling the lens capsule, the cannula was retracted
14 Multifocal IOLs

and the plug was moved to cover and seal the

opening in the capsule.
The lenses with zonula and ciliary body still
attached, after separating them from the adhering
vitreous body and sclera, were mounted in a lens
stretching device (Fig. 1) which was obtained
through collaboration with Dr. Adrian Glasser
(Houston, Texas, USA). This apparatus is capable of
applying radial stretching forces and it can be used
to study accommodative changes in natural and
refilled human lenses at various ages.7 The focal
length of the lenses mounted in the stretching device
is measured by a scanning laser ray trace technique.
Lens thickness and diameter can also be measured
simultaneously. Using the lens stretching device it
was shown that presbyopic natural human lenses Fig. 1: Stretch ring used to induce accommodative changes
in human lens, zonula and ciliary body specimens. Rotation
did not show accommodative changes. However,
of the outer ring resulted in an increase or decrease of the
after refilling a lens with a silicone material with a tension of the sutures. The optical power of the lens was
Young’s modulus comparable to that of 20-year-old measured along the optical axis of the lens
human lens, accommodative changes comparable to
those of 20-year-old human lens were measured, so is not an option as it will destroy the capsule and
this shows that, at least in this stretching model of result in leaking of the lens refill material. Therefore,
accommodation, lens refilling with this newly there is a need to remove, kill or make lens epithelial
developed material restores the ability to cells inactive to prevent capsular opacification. Van
accommodate.17 Kooten and co-workers19 developed a hyaluronate
solution which contains actinomycin D. Actinomycin
AMOUNT OF REFILLING D is a cytotoxic compound which intercalates with
DNA, resulting in a decreased RNA polymerase
Since the optical power of refilled lenses depends
(DNA reading) activity inhibiting RNA synthesis.
on the amount of injected material, additional
In an in vivo study in rabbits, after removing the
experiments were performed in pig eyes to establish
natural lens contents, the capsular bag was filled
the relationship between the amount of injected
with this hyaluronate solution, while the anterior
material and the optical power of the refilled lens.
chamber was filled with regular sodium hyaluronate
These experiments18 revealed that an additional 0.04
to protect the anterior chamber structures from
mL of injected refilling material increased the lens
coming into contact with the toxic substance. After
power by 1 D. This result indicates the filling accuracy
5 minutes, the hyaluronate-actinomycin solution was
required during the procedure. The exact technique
irrigated from the capsular bag and a refilling
to determine the required amount of filling during
silicone material was injected. A significant reduction
lens refilling surgery has yet to be determined.
in the amount of capsular opacification was noted 3
months after implantation of the refill lens when
CAPSULAR OPACIFICATION
comparing treated with untreated rabbit eyes. No
When most of the capsular bag is preserved as in damage to the other structures of the anterior
lens refilling surgery, there is a great potential for segment was clinically observable. This gave the
proliferation of lens epithelial cells which will result required confidence to proceed with lens refilling
in capsular opacification. Nd-YAG laser capsulotomy experiments in primates.

PRIMATE STUDY
Since primates are the only species showing
accommodation similar to the human eye, this
model20 was used to study accommodation after in
vivo lens refilling, mostly in collaboration with
Dr Adrian Glasser in Houston, Texas, USA. Prior to
accommodation studies, the rhesus macaque
monkeys which were used for this study underwent
a unilateral total iridectomy to visualize the whole
lens.
The surgical technique was similar to that used
in the human cadaver lens experiments (Fig. 2). A
clear corneal tunnel incision was made. The anterior
chamber was filled with sodium hyaluronate. With
a 27-gauge needle a small peripheral puncture of the
anterior lens capsule was made approximately 2 to
3 mm from the lens equator. With Utrata forceps, a
~ 1.5-2.0 mm diameter circular capsulorhexis was
completed in the lens periphery (Fig. 2A). A clear
cornea paracentesis was created using a 15° knife
and an anterior chamber maintainer connected to
an infusion bottle with physiologic saline solution
was inserted in the incision.
The lens substance was removed by aspiration
(Fig.2B). This was done manually by using a 20-gauge
blunt cannula connected to a 10-mL syringe with a
piece of polyethylene tubing. After removal of the
natural lens, the anterior chamber maintainer was
removed and the anterior chamber was filled with
sodium hyaluronate. The 1% sodium hyaluronate
solution containing actinomycin D as developed by
van Kooten et al. was injected in the monkey capsular
bag and left in place for five minutes in an effort to
lyse or kill the remaining lens epithelial cells and to
prevent the early development of postoperative
capsular opacification (Fig. 2C). After the five
minutes, the anterior chamber maintainer was
inserted in the corneal incision again and the
viscoelastic material was aspirated from the eye,
starting with the sodium hyaluronate solution in the
capsular bag. The inner anterior and posterior central
capsular bag surfaces were polished with a capsule
polisher as well as possible without risking capsular
rupture. Then, the anterior chamber was filled with
regular sodium hyaluronate. A custom made silicone
Accommodative Lens Refilling 15
membrane (US patent application 2002/0107567) with
a diameter of 2.7 mm (a capsular “plug”) was inserted
in the capsular bag through the capsulorhexis (Fig.
2D). The empty capsular bag was filled with the
polymer through the capsulorhexis, beneath the plug
by inserting a 25-gauge cannula into the bag and
injecting the refill polymer until the capsular bag was
judged by the surgeon to be completely filled (Figs
2 E, F, G). The cannula was retracted and the plug
was positioned to close the capsulorhexis. The
sodium hyaluronate was flushed out of the anterior
chamber with the saline solution via the anterior
chamber maintainer through the corneal incision.
Finally, both incisions were sutured and the anterior
chamber was reinflated (Fig. 2H).
Accommodation studies were performed
postoperatively under general anaesthesia.
Accommodation was stimulated by carbachol
iontophoresis to the anterior chamber or by
pilocarpin 4% drops and the refraction of the eye
under investigation was measured with a Hartinger
coincidence refractometer. The refractive change
before and after pharmacological stimulation of
accommodation represented the accommodative
amplitude. In five adolescent animals that were
treated according to a protocol involving an intense
postoperative treatment with steroid eye drops and
treating the capsular bag with the solution of
hyaluronate containing actinomycin D, accommo-
dation could be measured as an optical power change
during the 37-week follow-up period. A maximum
accommodative amplitude of 6.3 D was measured.
In three monkeys the accommodative amplitude
decreased to almost 0 D after 37 weeks. In the two
other monkeys the accommodative amplitude
remained stable at ±4 D during the follow up period.
Capsular opacification developed in the post-
operative period but refraction measurements could
still be performed during the whole follow up period
of 37 weeks. Most of the opacification occurred in
the mid periphery of the lens. These experiments
showed that a certain level of accommodation can
be restored after lens refilling in adolescent rhesus
monkeys. Despite a treatment aimed at its
prevention, capsular opacification occurred after
some time (Fig. 3).
16 Multifocal IOLs

Figs 2A to H:. Surgical procedure of lens refilling


Fig. 3: Slitlamp image of a monkey lens 2 years after
capsular bag refilling
CONCLUSION
Replacement of the crystalline lens with a synthetic,
soft material resulted in 4-6 D of accommodation
following pharmacological stimulation in young
primates for up to 37 weeks postoperatively. The
eyes were relatively clear, suggesting that an
injectable synthetic lens is a feasible way to treat
presbyopia. However, many more questions remain
to be answered before an injectable accommodative
lens can be used for human eyes. Permanent
prevention of capsular opacification is a major aspect.
Another challenge is the question of how to measure
and control the power of the injected lens during
surgery. In the context of the experiments described
in this chapter, the natural lenses were removed by
simple aspiration. A practical solution is needed for
the removal of the hard, stiff natural lens material
found in older cataract patients through a 1 to 1.5
mm opening in the lens capsule. However, given
the worldwide interest in the correction of
presbyopia, the prospects for further research and
development of accommodating lenses are excellent.
REFERENCES
1. Helmholtz, H: Über die Akkommodation des Auges.
A.v.Graefe’s Arch.Klin Ophthalmol 1855;1:1-74.
2. Krag S, Andreassen TT. Mechanical properties of the
human lens capsule. Prog Retin Eye Res 2003;22:749-67
Accommodative Lens Refilling 17
3. Pau H, Krantz J. The increasing sclerosis of the lens and
its relevance to accommodation and presbyopia. Graefes
Arch Clin Exp Ophthalmol 1991;229:294-96.
4 . Neider MW, Crawford K, Kaufman PL, et al. In vivo
videography of the rhesus monkey accommodative
apparatus. Age-related loss of ciliary muscle response to
central stimulation. Arch Ophtalmol 1990;108:69-74.
5. Friberg TR, Lace JW. A comparison of the elastic
properties of human choroid and sclera. Exp. Eye Res.
1988;47:429-36.
6. Fisher RF. Presbyopia and the changes with age in the
human crystalline lens. J.Physiol (Lond). 1973;228:765-
79.
7. Glasser A,Campbell M. Presbyopia and the optical
changes in the human crystalline lens with age. Vision
Res 1998;38:209-29.
8. Kessler J. Experiments in refilling the lens. Arch
Ophthalmol 1964;71:412-17.
9. Kessler J. Refilling the rabbit lens. Further experiments.
Arch Ophthalmol 1966; 76:596-98.
10. Agarwal LP, Narsimhan EC, Mohan M. Experimental
lens refilling. Orient Arch Ophthalmol 1967;5:205-12.
11. Agarwal LP, Narsimhan EC, Mohan M. Experimental
lens refilling. II. Orient Arch Ophthalmol 1967; 5:278-80.
12. Parel J-M, Gelender H, Treffers WF, Norton EWD. Phaco-
Ersatz: cataract surgery designed to preserve
accommodation. Graefe’s Arch Clin Exp Ophthalmol
1986; 224:165-73.
13. Haefliger E, Parel JM. Accommodation of an
endocapsular silicone lens (Phaco-Ersatz) in the aging
rhesus monkey. J Refract Corneal Surg 1994; 10:550-55.
14. Nishi O, Hara T, Hara T, Sakka Y, Hayashi F, Nakamae
K, Yamada Y. Refilling the lens with an inflatable
endocapsular balloon: surgical procedure in animal eyes.
Graefe’s Arch Clin Exp Ophthalmol 1992; 230:47-55.
15. Nishi O, Nishi K. Accommodation amplitude after lens
refilling with injectable silicone by sealing the capsule
with a plug in primates. Arch Ophthalmol 1998; 116:1358-
61.
16. Nishi O, Nishi K, Mano C, Ichihara M, Honda T.
Controlling the capsular shape in lens refilling. Arch
Ophthalmol 1997; 115:507-10.
17. Koopmans SA, Terwee T, Barkhof J, et al. Polymer
refilling of presbyopic human lenses in vitro restores the
ability to undergo accommodative changes. IOVS
2003;44:250-57.
18. Koopmans SA, Terwee T, Haitjema HJ, et al. Relation
between injected volume and optical parameters in
refilled isolated porcine lenses. Opht Phys Opt
2004;24:572-79.
19. van Kooten TG, Koopmans SA, Terwee T, et al.
Development of an accommodating intra-ocular lens –
In vitro prevention of re-growth of pig and rabbit lens
capsule epithelial cells. Biomaterials 2006;27:5554-60.
20. Koopmans SA, Terwee T, Glasser A, et al. Accommo-
dative lens refilling in rhesus monkeys. IOVS
2006;47:2976-84.
 3 How to Test Reading
Improvement after
Presbyopic Surgery?
The ability to read is essential for everyday life in
our modern, information-based society. 1 Pres-
byopia—the age related loss of accommodation—in
general becomes noticeable in emmetropes between
the ages of 40 and 45 years.2 It is one of the first
signs of aging as a result of the age-dependent
decline in the amplitude of accommodation. Since
1850, the Helmholtz theory of accomodation3 and
its modifications4-7 have attributed accommodation
to a decrease in zonular tension and presbyopia to
lens sclerosis and/or ciliary muscle atrophy. The
amplitude of accommodation reaches a peak in early
life, and then continuously declines. 8 Presbyopia
regularly occurs in an individual’s most productive
age, with the accommodative power no longer
allowing sustained and/or comfortable near vision
work. Losing the ability to read severely reduces a
person’s independence and thus has a severe impact
on the quality of life.9-10
The sheer number of the Presbyopic population
(according to current estimates there are currently
more than 1.3 billion presbyopes worldwide), and
the resulting size of the optometric/ophthalmic
market for presbyopia-correction products, are the
major driving forces for recent developments in this
area. 11 The number of potential patients for the
surgical correction of presbyopia is projected to grow
even more in the coming decades. The direction of
interest in refractive surgery is rapidly shifting
towards presbyopia, which is considered by many
to be its “final frontier”. 12 To attract this huge
“patient market”, a fully satisfying surgical solution
Alois K Dexl, Günther Grabner
for presbyopia is needed, but that has been an elusive
goal until now, with interesting options being
currently investigated.13
Several different approaches can be taken to
address this problem. Currently available surgical
techniques are:
• Intracorneal inlays with different modes of
action,14-15
• Multifocal corneal laser surgery,16-18
• Conductive keratoplasty,19-21
• Scleral expansion implants, 22-26 anterior ciliary
sclerotomy,27-28
• Multifocal phakic and pseudophakic IOLs29-32 and
pseudo-accommodating IOLs.33-36
Cataract and refractive surgery have developed
rapidly over the last decades.37 Clinical experience
and experimental work has led to the insight that
Snellen acuity is inadequate as a sole parameter for
describing the quality of vision outcome of refractive
surgical procedures.38-43 The determination of visual
performance is still the most important clinical
examination in ophthalmology, when dealing with
the potential benefits of various surgical procedures
which are available to correct presbyopia. 14-36
Therefore, the results of near vision tests have to be
very accurate, reproducible, and comparable. To achieve
this goal, the testing parameters of the various
measurement procedures have to be uniformly
standardized1,43-48 for both, distance visual acuity
and reading performance.
Refractive surgeons and clinicians often tend to
overlook that the visual system is composed of an
 How to Test Reading Improvement after Presbyopic Surgery? 19
optical component, and an important sensory
component that begins at the retinal photoreceptor
level and ends at the optical cortex.13 So when the
aim is just to test the “optical system”, at first look it
seems to be more appropriate only to test “pure”
near-visual acuity in cataract and refractive patients.
But indeed, reading is much more than just to be
able to discriminate single optotypes in an almost
unlimited time period. Therefore in all refractive
patients, not near-visual-acuity, but reading acuity
should be tested, because that is what the patient,
willing to undergo surgery, wants to regain post-
operatively.
For decades reading acuity has been tested with
the Jaeger charts, although the huge variability
between different charts has been well docu-
mented. 49 Colenbrander randomly collected 20
current cards with Jaeger numbers, and found a
variability of used print sizes of factor 3, which
represents 6 lines.49 It can therefore be concluded
that “Jaeger numbers” are by far not standardized
enough to be used in visual acuity studies, in parti-
cular in clinical trials which aim to compare different
surgical procedures for correcting presbyopia and
in studies comparing multifocal IOLs.14-36
LogMAR defines the minimal angle at which
2 points can be recognized as being 2. Although the
angular resolution is a factor in reading acuity, it is
not what has to be evaluated when examining reading
ability. 50 For a more precise documentation of
reading acuity LogRAD (logarithm of the reading
acuity determination) should therefore be used,50
and not LogMAR which should be used exclusively
for single-optotype visual acuity testing.
Some of these mandatory principles of the
standardization for vision tests outlined
above46,47,51-54 have already been used for the design
of new reading charts:1,54-55 Bailey and Lovie55 used
unrelated words of similar legibility to simul-
taneously determine reading acuity and speed, a
method that has also been applied to the MNRead
Acuity Chart51 and to the “Radner Reading Charts”
(RRC) that are available in different languages
already.1
Radner designed the RRC’s (for clinical use in all
types of ophthalmologic patients, e.g. cataract and
age-related macular degeneration) by the imple-
mentation of “sentence optotypes” in order to mini-
mize variations between the test items and to keep
the geometric proportions as constant as possible at
all distances. Thus, in cooperation with psychologists,
linguists, and elementary schools, Radner developed
a series of test sentences that are highly comparable
in terms of the number of words (14 words), word
length, position of words, lexical difficulty, and
syntactical complexity, by establishing over 30
definition rules. 1 The 24 most similar of these 32
sentences were selected statistically1,56 by evaluating
their reliability and validity for measuring reading
speed56 and were then used for the three different
RRCs in the standard reading test. Thus, the concept
of “sentence optotypes” for reading charts should
be capable to provide fully standardized clinical
measurements of reading acuity and speed.1,56
In clinical trials reading tests should be adminis-
tered in a randomized order when given in short
sequences,57-60 which is possible by using the three
different RRC’s. A choice of such test items, which
are highly comparable in terms of lexical difficulty,
reading length and construction, allows to optimise
the reliability and validity of reading performance
analyses when short sentences are used, especially
when intended to subsequently use them for analysis
of reading acuity.1 Reading speed with RRC can be
easily calculated on the basis of the number of words
in a sentence 14 and the time needed to read the
sentence (14 words × 60 sec ÷ reading time).50 We
have to be aware of the fact, however, that reading
speed is not only depending on the surgical skills or
the chosen procedures, but is indeed much more
affected by the sensory component of the visual
system.13 As far as reading speed is concerned there
seems to be one significant borderline: A reading
speed of 80 words per minute is the lower limit for
a recreational, sense-capturing reading perfor-
mance.61-62 In clinical trials this definite border should
attract much more interest than comparing reading
speed of different patients, respectively different
study groups. So sentences that are read with a
reading speed below 80, should not be considered
for inclusion in the statistical evaluation in visual
acuity trials.
20 Multifocal IOLs

Whereas currently available modern reading

charts seem to be quite standardized according to
the requirements for international standards of
visual acuity tests47-49,51,55-56 they still carry one major
disadvantage: reading acuity is either evaluated
under fixed distances (that are rarely measured
precisely) only, or these distances are even estimated
only or completely ignored. As it is well known that
patients do choose their optimal reading distance
according to body size and posture, personal
reading preferences and print size, it seems to be a
more “real-life” setting to let patients use their own,
subjectively convenient reading distance during
testing.
Currently no published method exists, which
allows to test reading acuity both under stan-
dardized circumstances and while simulating a
natural reading process, in order to get a better Fig. 1: Front view of the SRD
validation of the every day reading abilities of
patients. Since 2004 the University Eye Clinic of
Salzburg has been continuously working on the
development of a device for testing reading acuity
under standardized circumstances, in order to be
able to provide objective and thereby also
comparable results in different studies.
The SRD system (Figs 1 and 2) consists of a special
designed reading-desk, a personal computer (PC)
or laptop, a TFT display and a printer. The reading-
desk is mounted on a flat case which carries inside
the electronic measurement equipments, the chain-
impulse driver which allows adjusting the inclination
of the table from 0-40°, and a mounting device for
the two video-cameras facing the patient. The SRD
equipment allows accurate measurement of the
reading acuity (RA), taking into account the patient’s Fig.2: Side view of the SRD. Camera tripod with cardboard
individual, freely chosen, reading-distance and other and green color coding dot simulating a test situation in front
of the SRD. Measuring procedure: red arrows indicating
distinct parameters, such as reading time, illumi-
distance from cameras to green point; green arrow indicating
nation and inclination of the reading-table. The three reading distance
different available RRC’s are simultaneously used,
because they have been tested for validity and
reliability,1 and the results have been published in measuring reading acuity with a fixed distance does
various studies.1,50,56,58,60,63 not allow to draw conclusions on the “every day
The reading distance—by far the most critical reading ability” of the patients. The measurement
parameter in testing RA—seems to be very variable of this reading distance is realized by a continuous
and thereby quite different for every patient tested, short distance video-stereo-photometry with
when trial subjects are allowed to freely choose a additional software processing. For this purpose the
subjectively convenient reading distance. Therefore bridge of the patient’s nose is marked with a little
 How to Test Reading Improvement after Presbyopic Surgery? 21
colour coding dot. The perpendicular distance
between this point and the text-line on the corres-
ponding RRC is continuously monitored, displayed
and processed to indicate the RA in LogRAD. About
3-4 pictures are taken per second by two video-
cameras so that within an estimated reading time of
e.g. 5 seconds, the particular reading distance is
measured up to 20 times. The two cameras are
positioned on a specially designed mounting device
in a well defined height and distance to each other.
Via software processing the mean reading distance
within the corresponding reading period can be
calculated. The SRD-software has been developed
to cover possible reading distances between 15 cm
and 63 cm, at inclinations of the reading desk between
0° and 40°. The patient can adjust the inclination of
the SRD to a subjectively convenient position with a
push button on the front of the case, to offer the
most convenient test circumstances. The adjustment
is electromotorically enabled by a chain-impulse
driver and is monitored by a rotation sensor.
Two fluorescent tubes—which are emitting light
equivalent to daylight (5400 K, 40 kHz)—illuminate
the surface of the desk uniformly. The single
sentences of the RRC’s are mounted in a fixed
position on the desk in a specifically designed “text-
book”. This text-book has 12 pages. One for each of
the 12 smallest sentences of the 3 different available
RRC’s. Each RRC has in its original version 14
sentences, but the two biggest ones have been
omitted, because they are dedicated to test reading
acuity in patients with macular diseases. Therefore,
within this “textbook” the biggest sentence is
Sentence #3, and the smallest one is sentence #14.
These 3 “textbooks” are easily exchangeable to
prevent a possible recognition and learning/
memorizing effect of previously read sentences of
different “textbooks”. So overall 36 sentences in
different print sizes are available for testing. The
illumination of the corresponding RRC-Sentence is
automatically measured and regulated to a constant
value of 500 lx. This pre-adjusted illumination level
was chosen because of the consisting European norm
for the illumination of reading, respectively working
surfaces in bureaus and bibliographies.64 However
the operator is able to set the illumination to a
different value, if desired.
A microphone which is fixed in the plane of the
adjustable table gives a signal to the computer when
the patient is reading the sentences of the RRC aloud,
to visualize the reading process of the patient on
the user-interface of the SRD software (Fig. 3). After
the end of each reading process (a complete sentence
has been read by the patient) the examiner has to
define the beginning and the end of the reading
process by positioning two vertical lines (green line
= beginning, red line = end) on the user-interface of
the SRD-Software program (Fig. 4). By defining the
reading period, the software can automatically
calculate and display the following parameters:
• Reading time (maximum is 25s, measured in
seconds)
• Perpendicular distance between text-line of the
RRC and the green mark on the root of the nose
of the patient displaying the mean distance during
the specific reading period (measured in cm)
• Illumination of the RRC (preset to 500 lx)
• Inclination (reading angle) of the SRD (0 to 40°).
From these values the computer calculates and
displays:
• Reading Acuity in LogRAD,
• Reading velocity in words/minute (wpm).
Fig.3: SRD user interface: Upper white horizontal box
representing reading process (sound yes or no), lower
horizontal white box representing distance measurement
(simulated sinus curve). User has to define the reading
period by positioning a green vertical line to the beginning ,
and a red vertical line to the end of the reading process (as
told in the green info box)
22 Multifocal IOLs
Fig.4: After defining the reading period the SRD Software is
able to calculate the reading speed in words per minute
(Wpm), the distance corrected reading acuity (LogRAD), the
reading time in seconds, the mean distance for the defined
reading period in cm, the illumination of the reading surface
(Lux) and the inclination of the reading surface (reading angle
in degree)
Fig.5: Bland Altmann plot indicating the allocation of the single measurements. Comparison observed value to target
value. Red lines indicating limits of agreement (±0.5 cm from target value)
As distance measurement is the most important
parameter in testing reading performance with the
SRD, validity and reliability checks have been
performed with 2184 single measurements in
distances between 15 and 63 cm, and inclinations of
the reading desk between 0 and 40° (in 5° steps) to
check the whole testing spectrum currently possible.
Because the process of measuring the distance via
SRD-software is possible without any input of the
examiner, validity and reliability could be checked
with a simple procedure by correlating the calculated
distances from the SRD to a fixed reference value.
An acceptable fault tolerance of ±0.5 cm has been
set a priori. These acceptable measurement errors
have been chosen, because this value of error in
distance implies an error in LogRAD of ± 0.0034 at
63 cm and of LogRAD of ± 0.0143 at 15 cm, which is
of no clinical relevance.
Analysis shows that in 182 different measurement
situations, which have been each repeated 12 times
(= 2184 single measurements), a deviation of this
 How to Test Reading Improvement after Presbyopic Surgery? 23

Fig.6: Bland Altmann plot indicating the 95% confidence interval of comparison observed value to target value.
Red lines indicating limits of agreement (±0.5 cm from target value)

preset limits of agreement only occurred in 5 cases
(Figs 5 and 6). At all the other 177 measurement
situations all single measurements, as well as the
95% confidence intervals have been within this preset
range. Only in five test set-ups (two times at 63.1 cm
and 0°, once at 49 cm and 15°, and twice at 30.9 cm
and 25°) we missed this preset goal (single
measurements as well as 95% confidence-interval),
but overall in more than 95% of the measurements
we were able to stay within this defined acceptable
error range. Therefore one can postulate that the
SRD is a very valid and reliable method for measuring
reading distance, and calculating a distance corrected
reading acuity. As an upper distance a limit of 63 cm
has been chosen, the lower limit depends on the
desired inclination of the reading surface. Between
0°-10° of inclination, distance measurements can be
done between 24 and 63 cm. This lower distance
limit decreases with the increasing inclination of the
reading surface to 19 cm at inclinations between 15°
and 20°, and 15 cm at inclinations between 25° and
40°. Above 40° distance measurement is not possible,
because “the line of sight” of the two cameras used
for measurement is occluded due to the increasing
height of the upper border of the reading surface
with increasing inclination.
It is surprising that the signal detection theory65
and computer assistance have not been widely
exploited for the measurement of visual acuity,
although this methods provide a considerable
reduction of confounding influences.66 In an attempt
to fill this gap, the Freiburg Visual Acuity and
Contrast Test (FrACT), based on its antecessor, the
“Freiburg Visual Acuity Test”, was developed.67 The
“Freiburg Visual Acuity Test” can be used by the
patient, independent of any observer. 67,68
Wesemann 48 recommended the “Freiburg Visual
Acuity Test”, because of its continuous scale, which
is not limited to the traditional visual acuity steps,
as a reference procedure for testing visual acuity.
Nevertheless only the resolution of single optotypes
(“pure” near visual acuity) can be tested.
But also Contrast Sensitivity or low-contrast
visual acuity testing will also play a role in
24 Multifocal IOLs
determining the quality of vision. 69-73 The ideal
contrast test has not been found yet. Bühren et al37
showed that different tests show different charac-
teristics and results are not freely interchangeable.
A comprehensive evaluation of quality of vision
requires testing under a range of lighting conditions;
mesopic conditions may be more sensitive to optical
changes than photopic conditions. 73-74 Patients
frequently report symptoms only for mesopic or
scotopic conditions, whereas quality of vision under
photopic conditions may be unaffected.73,75 Many
tests for contrast sensitivity and disability glare lack
uniformity in test principles or standardization of
lighting conditions.72-79 Most tests have problems that
limit their use in clinical studies such as low reliability
and a high probability of “correct guessing”.76,79 The
variety of testing methods used in contrast sensitivity
studies, in addition to the even greater variety of
ambient and glare luminance conditions, makes it
difficult to compare results between studies.37 There
are large discrepancies in the test results between
currently available contrast sensitivity testing
methods, especially under different lighting condi-
tions. Results from different contrast sensitivity tests
are therefore not interchangeable.37
As Bühren pointed out, 37 for further clinical
studies on quality of vision, a single test for measu-
ring contrast sensitivity and disability glare, with
standardized ambient and glare luminance levels
that are closer to real-world conditions, is needed.
Because of that need, Bühren and his study group37
constructed the Freiburg Acuity and Contrast Test
(FrACT) to display the stimuli. It allows visual acuity
testing at defined contrast levels and contrast
sensitivity testing at defined optotype sizes
automatically and independent of the observer.37
The FrACT can be seen as an automated alternative
to ETDRS, extending its range both at the upper and
lower end and being safe from being learned by
heart on repeated testing.66-68 But with the FrACT
system only the testing of “pure” near visual acuity,
by displaying single optotypes, is possible. To get a
more complete evaluation on the real-life reading
abilities it is absolutely mandatory to test RA, and
not just near visual acuity.
As a future improvement of the original SRD-
prototype, work is currently in progress on the imple-
mentation of a high-resolution computer-display
(with about the same resolution as a X-ray display
with 0.16 pixel-interspace). This only very recently
available screen will allow our study group to use
different luminance levels and in addition different
contrast levels (Fig. 7). We have to be aware that all
currently commercially available reading charts are
using high contrast levels (approximately 85-95%).
The added feature of testing with different,
especially reduced contrast levels (as an example a
“normal” newspaper has only about 40-60% of
contrast) will probably allow to discriminate even
smaller differences regarding every day reading
abilities. This holds great promise in the comparison
of different surgical procedures for the improve-
ment of RA.14-36
As the investigating surgeon’s intention should
be to test under “every-day-conditions”, this will
be another step on the way to get more accurate,
repeatable and comparable results to assess the “real-
reading ability” of his trial subjects. By using the
above mentioned display the trial subjects can either
be presented with different charts for testing RA
(such as Radner Reading Charts), or with a setup
for assessing pure near visual acuity (such as Landolt
C-Rings) or other testing patterns, such as road maps,
music sheets, or graphics can be used. In addition
this advanced experimental design seems to be more
up-to-date, as more and more people (even in the
older age group) receive most of their information
Fig.7: SRD-advanced with integrated high-resolution display
for showing different near-vision or reading charts in variable
luminance and contrast levels
 How to Test Reading Improvement after Presbyopic Surgery? 25
from the computer – respectively the internet – and
it can also be expected that in the not to distant future
the computer will also partly replace the “old-
fashioned” printed books. Using hand-held reading
charts (with all the additional problems caused by
insufficient standardization) can thereby be
completely avoided, and standardized testing of RA
in all clinical settings envisioned.
In summary, with the use of the SRD it is possible
to continuously test the distance corrected RA for
the first time. This should become the standard of
care whenever the every day reading ability of
patients has to be assessed, as the patient can now
use his own subjectively convenient reading distance
and RA still can be very precisely measured. Studies
testing RA following several surgical methods (e.g.
with multifocal IOLs, new laser ablation profiles or
corneal implants) are currently under way in
Salzburg and other European centers with the use
of the SRD in order to firmly establish the validity
of this highly refined method for the evaluation of
RA.
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28 Multifocal IOLs
4
Importance of Reading Speed in
Multifocal IOL Implantation
INTRODUCTION
In our current society, reading is a crucial part of
everyday life and losing this ability leads to a
substantial reduction of quality of life.39,41,46,50,52,54
Often the re-establishment of the reading ability is
one of the principal motivations that convince the
patient to agree to a cataract operation.29, 49 Common
visual tasks as reading require us to analyze
impressive amounts of information at high rates.
How can we study the basic visual processes that
underlie the performance of these tasks?
WHAT IS READING?
The lack of a concise definition makes it difficult to
apply objective criteria to any measure of reading. It
is not easy to define what reading means, as it is a
generic term subject to interpretation. For example,
reading may be considered by some as working on a
computer, perusing a map, checking the newspaper
for the latest sports results. These kinds of activities
may not, in the strictest sense, be considered
reading. 38 Reading involves complicated mental
processes activated in the interpretation of concepts
and meanings that are stimulated by the recognition
of printed symbols. As such, there is universal
agreement among experts in the field of reading that
the best definition of reading is the ability to derive
meaning from text.24, 53 Carver9 reported five different
rates of reading: scanning, skimming, rauding,
learning, and memorizing. Scanning is the fastest rate
of reading and usually involves the reader searching
for a target word by looking at each consecutive word
Werner W Hütz
of a prose passage. Skimming is the second fastest
reading rate process. In this type, the reader is
searching a prose passage to find two adjacent words
whose order has been reversed or transposed. The
rate that is usually adopted while reading a prose
passage is rauding, a relatively new word defined as
reading with comprehension.9 Learning is slower than
rauding but more powerful. In learning, the aim of
the reader is to understand the information contained
in the passage. The slowest rate of reading is reading
to memorize.
What are the visual requirements for reading with
normal vision? Legge et al.24 measured reading rates
for text scanned across the face of a TV monitor while
varying parameters that are important in current
theories of pattern vision. The results provide
estimates of the stimulus parameters required for
optimal reading of scanned text. They found that
maximum reading rates are achieved for characters
subtending 0.3° to 2°.
Contrast polarity (black on white vs white on black
text) has no effect. Reading rate increases with field
size, but only up to 4 characters, independent of
character size. When text is low-pass spatial-
frequency filtered, reading rate increases with
bandwidth, but only up to two cycles/character,
independent of character size.
When text is matrix sampled, reading rate
increases with sample density, but only up to a critical
sample density which depends on character size. The
critical sample density increases from 4 × 4 samples/
character for 0.1² characters to more than 20 ×
20 samples/character for 24 characters.
 Importance of Reading Speed in Multifocal IOL Implantation 29

How does contrast affect reading rate? What is RADNER READING CHARTS
the role of contrast sensitivity? Legge et al 24
For this purpose, Radner et al39 have developed a
measured reading rate as a function of the contrast
new type of reading chart for the simultaneous
and character size of text for subjects with normal
evaluation of reading acuity and reading speed. This
vision. Reading rates were highest (about 350
chart is the result of cooperation with linguists,
words/min) for letters ranging in size from 0.25° to
psychologists and computer scientist and is in
2°. Within this range, reading was very tolerant to
accordance with the current international standards
contrast reduction, for 1° letters, reading rate
for visual acuity measurements and psychophysical
decreased by less than a factor of two for a tenfold
requirements for controlling optical item
reduction in contrast. The results were very similar
interactions.9
for white-on-black and black-on-white text. Reading
The Radner Reading Charts consist in 24 very
rate declined more rapidly for very small (< 0.25°)
simple sentences, developed to be highly comparable
and very large (> 2°) letters.
in terms of grammatical difficulty as well as in
The reading performance of an individual can be
number of words, length and position of the words.
measured simply and objectively by using two
The phrases have been created to perform reading
variables - reading speed and reading rate. Reading
acuity and reading speed measurements disregarding
speed is a measure of the number of words that the
the intellectual level of the reader. Everybody who is
reader can read per minute or per second, and it only
able to read can read these phrases and can derive
assesses the speed with which one reads. Reading rate
meaning from text.38 This approach was validated in
is measured by determining the correctly read words
a study in which Radner compared reading acuity
per minute and requires accuracy from the reader.
and speed of 80 university students and 80 blue collar
The reading speed refers to how fast can words can
apprentices and no statistical difference between these
be read whereas reading rate is used when accuracy
two groups with respect to reading speed was found
is the main goal or aim. As such, reading rate seems
(211,8 words/min ±34,1 (SD) measured in photopic
to be a more valid measure of assessing one's reading
conditions at 90-100 cd/m²).39
performance. The advantage of using these metrics
With Radner Charts, patients are allowed to
in the assessment of reading performance is the easy
choose their preferred reading distance which reflects
measurement, thus avoiding special instructions for
what patients do in real life. The distance is recorded,
patient and requiring a minimum of equipment. The
and then a nomogram is used for distance correction
major disadvantage is that neither rate provides an
at the bottom of each Reading Chart and final values
indicator of understanding, as the measurements
are expressed in LogRAD Scores. Reading speed can
focus on the number of words read per minute.
be measured across different print sizes with reading
It is legitimate to question the relevance and
speed declining with very big or very small characters
objectivity of reading measures for clinical purposes
and plateaus over a wide range in between. 24,25
since reading is a complex cognitive and linguistic
Reading rate can be calculated simultaneously
process and therefore by definition difficult to define
considering reading errors in words of different
and assess. As mentioned above, there is a common
length.
agreement among the experts in the field that the best
definition of reading is certainly the ability to derive
READING ACUITY AND READING SPEED AFTER
meaning from text. Therefore, successful reading
CATARACT SURGERY
would depend upon having available a repertoire of
decoding and comprehension skills and strategies So far, the common approach for treating cataracts
which would imply that the reader has a certain level has been the replacement of the crystalline lens with
of education. However, our primary goal as a monofocal intraocular lens (IOL). However, if this
ophthalmologists is to find out what affects patient standard procedure can fully rehabilitate distance
reading abilities disregarding the intellectual level of vision in cataract patients, it does not allow near
the person tested. vision. Furthermore, if older people with already
30 Multifocal IOLs
reduced or loss of accommodation accept the
postoperative dependence on reading glasses,
younger patients however with still good
accommodation ability feel this sudden loss
frustrating and handicapping.
Current alternatives for alleviating the loss of
vision include monovision, accommodative IOLs and
multifocal IOLs.31 With monovision, the dominant eye
is focused for distance vision, and the non-dominant
eye is focused for near to intermediate vision.
However, not all patients will adapt to monovision,
as there is a loss of depth perception. 14 With
accommodative IOLs, the amount of successful
accommodation is very variable and the rate of
posterior capsule opacification very high.42
Multifocal intraocular lenses (MIOL) appeared
only relatively late in the evolution of IOLs.4 Early
trials with MIOLs were disappointing due to poor
surgical techniques that induced astigmatism and
caused decentration 3,4,5,10,12,21,26,31 Moreover,
reduced contrast sensitivity along with high
occurrence of halos and glare were among the
drawbacks widely reported by patients.2, 5, 6, 7, 15,16,17
The development of the Array® SA40N has been a
major step towards a safer and effective treatment
for presbyopia and cataract with high levels of
patient satisfaction. 8,13,18,19,36,43,44 However, more
recently, second-generation MIOLs including the
Tecnis® ZM001 and the Acrysof ReSTOR® SA60D3,
have emerged as more performant, providing
greater independence from glasses along with a
reduction of glare and halos.
In this prospective study, we evaluated and
compared the reading performance of patients after
bilateral implantation with the refractive Array®
SA40N, the diffractive Tecnis® ZM001 and the
diffractive Acrysof ReSTOR® SA60D3 IOLs. We used
the standardized Radner Reading Charts® which
provide reliable measures for clinical and scientific
analyses of reading performance.45
PATIENTS AND METHODS
60 cataract patients were randomly assigned to
receive one of the three multifocal IOLs; the Array®
SA40N (n = 20, group I), the Tecnis® ZM001 (n = 20,
group II) and the Acrysof ReSTOR® SA60D3 (n = 20,
group III). The Array® SA40N IOL (AMO, Inc.) is a
foldable silicone zonal progressive multifocal IOL
which features a 6.0 mm optic with five concentric
refractive zones of near and distance powers. Zones
1, 3 and 5 are distance dominant to form the base
power, and zones 2 and 4 are near dominant with
3.5 D added. The Tecnis® ZM001 IOL (AMO, Inc.)
is a foldable silicone diffractive IOL which features
a 6.0 mm optic. This lens combines diffractive optic
technology with an aspheric modified prolate anterior
surface designed to reduce spherical aberrations. The
diffraction pattern creates two major focal points that
are 4 D apart. The Acrysof ReSTOR® SA60D3 IOL
(Alcon laboratories) is a foldable acrylic apodized
diffractive IOL which features a 6.0 mm optic with
an add power of 4 D. It has a hybride diffractive/
refactive optic with 3.6 mm central part consisting
in concentric diffractive steps while the periphery is
identical to a monofocal acrylic IOL.
Inclusion criteria were a minimum age of 50 years,
availability for postoperation examinations and a
consent agreement for the surgery. Exclusion criteria
included higher cornea astigmatism over 1.0 D, a
pupil size smaller than 2.4 mm, an extreme ametropia
(available range) and ocular pathologies such as
amblyopia, corneal dystrophia, keratoconus,
retinopathy, glaucoma, ocular atrophy, iris atrophy,
uveitis, retinal dystrophy, condition after retinal
detachment, condition after ocular surgery. Exclusion
criteria also included potential complications during
the surgical procedure such as rupture of the capsule
or zonulolyse. After obtaining the patient's written
informed consent, a standardized preliminary visual
assessment was performed. Pre-operative pupil size
was measured under photopic conditions in order to
select only patients with a pupil size over 2.4 mm.
All patients had preoperative biometry using the IOL
Master®. The results were then included in the SRK
T formula to calculate the intraocular lens power. The
next available diopter (plus direction) was chosen for
implantation. Therefore, target refraction was
emmetropia up to slight overcorrection. Patients were
operated under standardized procedure by two
experienced surgeons (random distribution between
patients). Cataracts were extracted by phacoe-
mulsification through a clear corneal incision of
3.2 mm. MIOLs were implanted into the capsular
bag using their respective injector. Time between
 Importance of Reading Speed in Multifocal IOL Implantation
the two surgeries was 14 days. All patients
underwent full ocular examination two weeks after
surgery to confirm the healing process. A further
clinical examination took place 6 weeks after the
operation of the second eye. Standardized pupil size
measurements were made under different lighting
conditions at the millimetre scale of the ocular of
the Goldmann perimeter. Under low and bright light
conditions the average light density in the perimeter
hemisphere was 6 cd/m² and 100 cd/m², respectively
(Mavolux digital, Firma Gossen, Germany).51
READING ACUITY AND READING SPEED
Reading acuity was tested with the Radner Reading
Charts® at a luminance of 6 cd/m² and 100 cd/m².
The Radner Reading Charts® have been designed
according to internationally accepted principles of
standardisation.25,35 Radner et al39 have developed
sentence optotypes to minimize variations between
the test items and to keep the geometric proportions
as constant as possible at all distances to achieve
accurate and standardized measurements of reading
acuity and reading speed at every viewing distance.
As a result, one can achieve highly comparable
sentences in terms of number of words, lexical
difficulty, and syntactical complexity.39,45,46 The only
stimulus variable is the size of the sentence
optotypes, which is graduated in 0.1 log unit steps
(ratio 1.26:1) equivalent to the EN ISO 8596. 23
Reading acuity was determined as the smallest print
size that could be read and expressed in LogRAD.
Reading speed measurement was made by
recording the reading time for a text with print size
of LogRad 0.4 (Snellen 0.4), a print size that is
generally used in newspapers and books. A training
session was not conducted because studies have
shown no learning effect over time.1 Patients were
asked to read a sentence binocularly as quickly and
accurately as possible while the other sentences were
covered with a piece of paper. Reading speed in
words per minute (words/min) was calculated based
on the number of words in a sentence and the time
needed to read the sentence (14 words × 60 seconds
divided by the reading time). The reading speed
for print size LogRad 0.4 (Snellen 0.4) was defined
as the best reading speed measurement achieved in
the test.
31
STATISTICAL METHODS
Data collection, data management and data analysis
were performed using the statistical package SPSS®
Version 13.0. The variables were ordinal scaled (e.g.
visual acuity) and when a normal distribution was
not expected (e.g. reading speed, pupil size) non-
parametric tests were used to determine statistical
significance. Kruskal-Wallis test was used to test
global statistical significance between the three
groups of lenses. If this test showed statistical
significance (p<0.05) then Wilcoxon-Mann-Whitney
test was used to calculate pair-wise statistical
significance between the groups (group I vs II, group
I vs III and group II vs III). Variation of the pupil size
between the three groups was assessed using the
median-test.
RESULTS
Residual Refractive Error
At the 6-week post surgery visit, mean residual
spherical error was + 0.5 D in patients from group I,
+ 0,5 D in patients from group II and ± 0.0 D in
patients from group III. Residual astigmatism was
± 0.0 D in group I, ± 0.0 D in group II and less than
–0.5 D in group III.
Pupil Size
Measurement of the pupil size under different
lighting conditions did not reveal any significant
differences between the three groups. Under low light
conditions with 6 cd/m², average pupil size was
4.0 mm in group I (median 4.0, SD 0.51), 3.5 mm in
group II (median 3.5, SD 0.73) and 3.63 mm in group
III (median 3.63, SD 0.59) (median-test, p = 0.20).
Under bright light conditions with 100 cd/m²,
average pupil size was 3.0 mm in group I (median
3.0, SD 0.38), 2.5 mm in group II (median 2.5, SD
0.52) and 2.75 mm in group III (median 2.75, SD 0.41)
(median-test, p = 0.71).
Reading Acuity
Near vision was first tested under low light
conditions (6 cd/m²). Mean reading acuity without
correction was 0.41 0.12 LogRAD in group I, 0.27
0.09 LogRAD in group II and 0.43 0.16 LogRAD in
group III. When the residual refractive error was
32 Multifocal IOLs

corrected (best distance correction), group I achieved
0.40 0.12 LogRAD, group II 0.23 0.08 LogRAD and
group III 0.41 0.15 LogRAD. It is known from other
studies that about 70 to 80% of the patients with
MIOLs live without reading glasses and that 20 to
30% still need reading glasses. We wanted to
simulate this situation and let all our patients read
with their preferred near correction: Group I reached
0.27 0.10 LogRAD, group II 0.22 0.07 LogRAD and
group III 0.30 0.11 LogRAD (Table. 1). The best near
visual acuity, with or without correction, achieved
in the Tecnis® ZM001 group was significantly
different to group I and III (Table. 2) whereas group
I and III performed similarly.
Under bright light conditions (100 cd/m²), mean
visual acuity without correction was 0.33 0.15
LogRAD in group I, 0.09 0.08 LogRAD in group II
and 0.14 0.12 LogRAD in group III. When the residual
refractive error corrected (best distance correction),
group I achieved 0.29 0.12, group II 0.04 0.08 and
group III 0.14 0.12. With best near correction group I
reached 0.12 0.12, group II 0.03 0.07 and group III 0.11
0.11 (Table 1). Under bright conditions, the
difference between groups was less striking. The
Tecnis® ZM001 group still performed on the whole
better than group I and III, but the Acrysof ReSTOR®
group achieved significantly better visual than group
I (Table 2).

Table 1: Reading acuity measured under different light conditions. Values are expressed in LogRAD-score

IOL
6 cd/m² 100 cd/m²
Un- Best far Best near Un - Best far Best near
corrected correction correction corrected correction correction
Array® SA40N N 20 20 20 20 20 20
mean 0.4108 0.4018 0.2722 0.3335 0.2928 0.1245
SD 0.1280 0.1222 0.1020 0.1531 0.1221 0.1242
median 0.3875 0.4025 0.2575 0.3450 0.3025 0.0875
Tecnis® ZM001 N 20 20 20 20 20 20
mean 0.2750 0.2326 0.2195 0.0910 0.0488 0.0329
SD 0.0962 0.0868 0.0752 0.0856 0.0825 0.0791
median 0.3000 0.2100 0.2100 0.1050 0.0500 0.0200
Acrysof® N 20 20 20 20 20 20
ReSTOR® mean 0.4358 0.4093 0.3063 0.1425 0.1380 0.1092
SA60D3 SD 0.1629 0.1568 0.1120 0.1235 0.1288 0.1169
median 0.3800 0.4000 0.3075 0.1325 0.1275 0.0825

Table 2: Statistical significance of the differences between the three groups in terms of visual acuity, measured
under 6 cd/m² and 100 cd/m². *P values were considered as significant if < 0.05 (Mann-Whitney-test)
6 cd/m² 100 cd/m²
Compared groups p value Compared groups p-value
Uncorrected A-T p < 0.001* A-T p < 0.001*
A-R p = 0.957 A-R p < 0.001*
T-R p = 0.001* T-R p = 0.210
Best far correction A-T p < 0.001* A-T p < 0.001*
A-R p = 0.807 A-R p < 0.001*
T-R p < 0.001* T-R p = 0.014*
Best near correction A-T p = 0.092 A-T p = 0.018*
A-R p = 0.401 A-R p = 0.694
T-R p = 0.011* T-R p = 0.030*

A - T = Array® SA40N vs Tecnis® ZM001; A - R = Array® SA40N vs Acrysof® ReSTOR®; T - R = Tecnis® ZM001 vs
Acrysof® ReSTOR®
 Importance of Reading Speed in Multifocal IOL Implantation 33

Reading speed
The reading speed was also determined using the
Radner Reading Charts® and was first tested under
low light conditions (6 cd/m²). The mean reading
speed without correction was significantly faster in
the Tecnis® ZM001 group with 142 w/min compared
to 68 w/min in group I and 72 w/min in group III.
Similarly, with best distance correction, the Tecnis®
ZM001 group achieved the best score with 140 w/
min compared to 87 w/min in group I and 80 w/min
in group III. With best near correction, group I
considerably improved to 105 w/min, group II
remained stable with 138 w/min and group III
improved to 100 w/min (Table 3). The difference
between group I and group III was not significant
(Table 4).

Table 3: Reading speed (words/min) measured under different light conditions.

IOL
6 cd/m² 100 cd/m²
Un- Best far Best near Un - Best far Best near
corrected correction correction corrected correction correction
Array® SA40N N 20 20 20 20 20 20
mean 67.98 86.98 104.83 87.27 96.77 142.96
SD 56.99 58.55 46.77 62.03 50.41 34.00
median 67.02 97.42 107.53 80.35 92.13 143.71
Tecnis® ZM001 N 20 20 20 20 20 20
mean 141.76 140.02 137.86 174.92 170.64 168.63
SD 42.83 47.69 43.76 30.22 34.64 34.15
median 142.86 136.36 139.30 170.04 182.61 176.84
Acrysof® N 20 20 20 20 20 20
ReSTOR® mean 71.73 79.40 100.13 138.20 131.22 123.65
SD 55.89 59.95 45.30 45.70 50.85 30.00
median 86.23 99.89 106.40 145.63 129.23 117.97
Table 3:

Table 4: Statistical significance of the differences between the three groups in terms of reading speed, measured
under 6 cd/m² and 100 cd/m². *P values were considered as significant if < 0.05 (Mann-Whitney-test)

6 cd/m² 100 cd/m²

Compared groups p value Compared groups p-value
Uncorrected A-T p < 0.001* A-T p < 0.001*
A-R p = 0.701 A-R p = 0.004*
T-R p < 0.001* T-R p = 0.007*
Best far correction A-T p = 0.007* A-T p < 0.001*
A-R p = 0.672 A-R p = 0.030*
T-R p = 0.004* T-R p = 0.008*
Best near correction A-T p = 0.054 A-T p = 0.025*
A-R p = 0.787 A-R p = 0.058
T-R p = 0.026* T-R p < 0.001*

A - T = Array® SA40N vs Tecnis® ZM001; A - R = Array® SA40N vs Acrysof® ReSTOR®; T - R = Tecnis® ZM001 vs
Acrysof® ReSTOR®
34 Multifocal IOLs
Similarly to the visual acuity data, under bright
light conditions (100 cd/m²) Tecnis® ZM001 patients
performed on the whole better than patients from
group I and group III and the Acrysof ReSTOR®
patients did better than group I (Table 3). The reading
speed without correction was significantly faster in
group II, with 175 w/min reached, compared to 87
w/min in group I and 138 w/min in group III. With
best distance correction, group I accomplished 97 w/
min, group II 171 w/min and group III 131 w/min.
With optimal near vision, patients from group I were
able to read 143 w/min, patients from group II 169
w/min and patients from group III 125 w/min
(Table 3). P-value data are summarized in Table 4.
DISCUSSION
In the present study, we evaluated the reading
performance of cataract patients after bilateral
implantation of three different types of multifocal
IOLs: Array® SA40N, Tecnis® ZM001 and Acrysof
ReSTOR® SA60D3. Overall, the Tecnis® ZM001
group performed considerably better than the Acrysof
ReSTOR® SA60D3 and the Array® SA40N groups
under all light conditions tested. However, Acrysof
ReSTOR® SA60D3 showed its superiority over
Array® SA40N under photopic conditions.28,33
Both the Tecnis® ZM001 and the Acrysof
ReSTOR® SA60D3 IOLs incorporate optical
principles that are new to IOL design. The Tecnis®
ZM001 combines a principle of diffraction with a
prolate, anterior surface designed to reduce spherical
aberrations. The latter was intended to benefit the
patient in terms of contrast sensitivity, particularly
under mesopic conditions as previously reported with
the monofocal model. 22,27,31,32,40,47,48 The AcrySof
ReSTOR® SA60D3 IOL uses an apodization process
to create concentric steps on the lens surface, which
produces a hybrid diffractive/refractive optic. With
its relatively small central multifocal zone, the Acrysof
ReSTOR® SA60D3 IOL was designed to maintain
near vision while improving distance acuity. A major
advantage of the diffractive principle is that
multifocality is independent from pupil size and light
is distributed evenly within each section of the optic.
This is very different for multifocal IOLs based on a
principle of refraction. Adequate functional pupil
sizes and optimal centration of the IOL is fundamental
to achieve good far and near visions.10,20,21,23,26,34
Taking this into account, we particularly paid
attention to measurement of our patient pupil sizes.
They were measured exactly under the same
conditions as the patients had to undergo the reading
tests.
The mean pupil size of our patients was not
significantly different between the three groups but
was nonetheless relatively small with an average size
of less than 3.0 mm under bright light and less than
4.0 mm under low light conditions. Since the Array®
SA40N IOL is pupil-dependent for its near and far
vision, we could anticipate that the reading
performance of the Array® SA40N patients would
be affected by such small pupils. This is well reflected
in our results with the poor uncorrected reading
capabilities in this cohort of patients. The Array®
SA40N IOL has five refractive zones that are designed
within a diameter of 4.7 mm with a far portion located
in the central 2.1 mm zone. For a pupil size of 2.8 mm
50% of the light is used for the far, 38% for the near
and 12% for the intermediate focal point.4 As the
average Array® SA40N pupil size was close to
3.0 mm under bright light conditions, the central far
dominant portion of the IOL and only a small portion
of the near zone were used. In other words patients
had to perform the tests mostly above the limit of their
possibilities. The fact that the Array® SA40N IOL has
only a near addition of 3.5 D could have also
contributed to its poor near vision performance.
Indeed, after best near correction, patients improved
considerably their reading performance, but still, the
Tecnis® ZM001 achieved better outcomes.
Based on the design of the Acrysof ReSTOR®
SA60D3, we expected reading performance to be
independent from pupil size. However, if under
bright conditions, reading acuity of patients
implanted with Acrysof ReSTOR® SA60D3 was
slightly worse but not statistically significant different
from the Tecnis® ZM001 group, the difference
between the two groups became apparent under
mesopic conditions. More striking was the poor
reading speed of the Acrysof ReSTOR® SA60D3
group under photopic conditions (138 + 45 w/min)
which did not exceed the reading speed of the Tecnis®
ZM001 group under mesopic conditions (142 +
43 w/min). In fact, optical bench testing
 Importance of Reading Speed in Multifocal IOL Implantation
demonstrated that the Acrysof ReSTOR® SA60D3
is, to a certain extend, sensitive to pupil size
compared to the Tecnis® ZM001.45 US Air Force Grid
projections through both IOLs showed that image
resolution through the Acrysof ReSTOR® SA60D3
decreased with increasing pupil size, for both far
and near distances (Figs 1 and 2). This weakness
can only be explained by the combined refractive
and diffractive design of the Acrysof ReSTOR®
SA60D3 where pupil independency is obviously
partially lost.
The Tecnis® ZM001 is a true diffractive lens,
where the light distribution is 41% for far, 41% for
near and the remaining 18% is lost due to higher order
scattering. As shown in our results, the performance
of the Tecnis® ZM001 is independent from pupil size.
As a result, very good reading capabilities (near visual
acuity and reading speed) were achieved under
different lighting conditions (6 and 100 cd/m²). These
data corroborate the previous findings from
photographed images of US Air Force Grid
projections as described above (Figs 1 and 2). The
clear superiority of the Tecnis® ZM001 IOL over
Array® SA40N IOL is also in line with another study
in which the diffractive MIOL performed better than
Fig. 1: US Air Force Target Projections photographed through
Tecnis® ZM001 IOL and Acrysof® ReSTOR® IOL with the
same shutter speed for all photos - focused for far45
35
Fig. 2: US Air Force Target Projections photographed through
Tecnis® ZM001 IOL and Acrysof® ReSTOR® IOL with the
same shutter speed for all photos - focused for near45
the refractive MIOL in terms of reading speed. 40
From a practical point of view, our data signify that
patients with a Tecnis® ZM001 would be able to read
a menu printed in small letters without glasses
during a candle-light dinner, whereas patients with
an AcrySof ReSTOR or an Array SA40N would
clearly have difficulties.
Reading speed measurement is a psychophysical
and objective examination that provides much more
information about functional vision than visual acuity
measurement does. This is because reading is the
endpoint the patient wants to reach and because
reading involves a larger retinal area and provides
topographic information. As the standard charts
(Jaeger, Snellen, Birkhaeuser, Zeiss, etc.) can only
assess the reading visual acuity which is a poor
predictor of performance on real-world tasks, there
is now a general trend towards the use of per-
formance-based tests. In the present study, we used
the Radner Reading Charts®, a German adaptation
of the American reading test MNRead Acuity Chart
developed by Mansfield, et al27, both designed to
allow simple and quick measurements of reading
acuity and reading speed simultaneously. For the
general comprehension of reading performance and
the clinical application of reading tests it is however
important to distinguish between the maximum
36 Multifocal IOLs
reading speed, which is achieved at large print sizes
and which can be used as a diagnostic clinical
test10, 11,12,15,29,30, and the highest reading speed with
smaller print sizes as used in this study. Investigating
reading speed using smaller print sizes of LogRAD
0.4 is particularly relevant since it simulates everyday
life situations such as reading newspapers, books,
magazines, etc. 43 , the text of which is generally
printed in 0.4 LogRAD size.
In conclusion, our study showed that under
bright light conditions, the diffractive Tecnis® ZM001
and Acrysof ReSTOR® SA60D3 MIOLs perform
overall better than the refractive Array® SA40N
group in terms of reading capability. However,
under low lighting conditions, the Tecnis® ZM001
IOL clearly provides better outcomes than its
counterparts. With the technical refinement of
second-generation MIOLs along with performance-
based tests, surgeons have currently new opportu-
nities to improve and assess visual outcomes of a
multitude of cataract patients as well as refractive
and presbyopic individuals.
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40. Ricci F, Scuderi G, Missiroli F, Regine F, Cerulli A. Low
contrast visual acuity in pseudophakic patients implanted
with an anterior surface modified prolate intraocular lens,
Acta Ophthalmol Scand 2004;82:718-22.
41. Richter-Mueksch S, Weghaupt H, Skorpik C, Velikay-
Parel M, Radner W. Reading performance with a
37
refractive multifokal and a diffraktive bifocal intraocular
lens. J Cataract Refract Surg 2002;28,1957-63.
42. Stachs O, Schneider H, Stave J, Schmitz KP, Terwee T,
Guthoff R. The anterior segment in rabbit eyes after lens
refilling with injectable silicone polymer, ARVO Meeting
abstract 2003;44,273.
43. Steinert RF. Visual outcomes with multifocal intraocular
lenses. Current Opinion in Ophthalmology 2000;11:12-
21.
44. Steinert RF, Aker BL, Trentacost DJ, Smith PJ, Tarantino
N. A prospective comparative study of the AMO Array
zonal-progressive multifocal silicone intraocular lens and
a monofokal intraocular lens, Ophthalmology
1999;106(7):1243-54.
45. Stifter E, König F, Lang T, Bauer P, Richter-Müksch S,
Velikay-Parel M, Radner W. Reliability of a standardized
reading chart system: Variance component analysis, test-
retest and interchart reliability. Grarfes Arch Clin Exp
Ophthalmol 2004;242(1),31-39.
46. Stifter E, Sacu S, Weghaupt H, König F, Richter-Müksch
S, Thaler A, Velikay-Parel M, Radner W. Reading perfor-
mance depending on the type of cataract and ist predicta-
bility on the visual outcome. J of Cataract Refract Surg
2004;30,1259-67.
47. Teping C, Oran E, Backes-Teping C. Visual acuity at
twilight and contrast vision in Patients with bifocal IOL.
Der Ophthalmologe 1994;91(4),460-64.
48. Terwee T, Holland. Presented at the annual meeting of
the ESCRS 2004, Paris, personal communication.
49. Uusitalo RJ, Brans T, Pessi T, Tarkkanen A. Evaluating
cataract surgery gains by assessing patients quality of
life using the VF-7, J Cataract Refrakt Surg 1999;25,989-
94.
50. Wiemer C, Pham DT, Wollensak J. Kann die diffraktive
Multifokallinse als Routinelinse implantiert werden? Der
Ophthalmologe 1994;91,450-53.
51. Wilhelm H, Wilhelm B, Lüdtke H. Pupillographie-
Prinzipien und Anwendungsmöglichkeiten. Z prakt
Augenheilkd 1996;17,327-36.
52. Winther-Nielsen A, Corydon L, Olson T. Contrast
sensitivity and glare in patients with a diffractive
multifocal intraocular lens, J Cataract Refract Surg 1993;
19(2),254-57.
53. Whittaker SG, Lovie-Kitchin J. Visual requirements for
Reading. Optom Vis Sci 1993;70:54-65.
54. Wollensak J, Pham DT, Wiemer C. Klinische Ergebnisse
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38 Multifocal IOLs

5
Multifocal IOLs and
Dynamic Vision

Carlos Vergés

FUNCTIONAL ORGANIZATION OF The P-pathway splits to produce two new

THE VISUAL SYSTEM pathways in the upper layer of V1. One pathway
seems to deal primarily with color and this is called
Vision is the primary sensory modality in humans
the P-B pathway. Neurons in the second pathway
and primates and this is reflected in the complexity
are sensitive to features such as the orientation of
of the visual system and the extent of the cerebral
cortex used for the analysis of visual information. It
is believed that at least 32 separate cortical areas are
involved with the processing of vision.1 The visual
system is not only organized in a serial, hierarchical
pathway, different aspects of a stimulus (shape, color
and motion) are analyzed in separate parallel
pathways. These pathways are usually divided in
two broad categories, “what” and “where”. The
“what” pathway deals with information about the
stimulus feature, such as shape and color, and the
identity of an abject and it can be subdivided into
two further pathways, color and shape. The “where”
pathway deals with especial information about an
object and is usually subdivided into motion and
form derived from motion.
The axons from the retina and Lateral Geniculate
Nucleus (LGN) terminate on cortical neurons in layer
4 (Fig. 1). The P layer neurons send their axons to
neurons in the deeper part of this layer, 4Cβ, which
in turn send their axons to layer 2 and 3 and from
there to V2. The M layer neurons send their axons
on neurons in sub layer 4Cα, and the information is
then sent to layer 4β and then to V2 and to V5. Cells
in layer 4β are orientation selective and most show
Fig. 1: A schematic organization of the visual system,
selectivity for the direction of movements. Some of subcortical and cortical pathways, with the two main
these neurons are binocular and show sensitivity to channels, the Parvocellular (P) and the Magnocellular (M)
retinal disparity.2 and the third pathway the Koniocellular (K)

the stimulus and seem to mediate high acuity
perception. This pathway is called the P-I pathway.
There is a third type of cell in the LGN, called
Koniocells and are found within the gaps between
the M and P layers. They are believed to receive
inputs from P-cells, one of the cell types that make
up the remaining 10% of retinal ganglion cells. This
cells also project to V1 and the so called P pathway
actually receives input from the P, M and W neurons
of the LGN.
The organization of V1 is retinotopic that is the
visual field of the retina is mapped onto the surface
of the cortex of V1. In V2 there seems to be three
separate visual maps, a visual orientation map, a
color map and a disparity map.3 Neurons from V1
project to V2. The P-B pathway to the thin stripes of
V2 and the P-I pathway to the interstripes of V2.
Both subdivision of the P pathway, the thick stripes
(color) and interstripes (form) project to V4. Some
of those V4 cells that are sensitive to color seem to
display a higher elaborate task, the color constancy.4
V4 projects primarily to the temporal visual cortex,
where there seems to be an integration of form and
color to give a representation of complex objects.
Neurons in this region are responsive to complex
patterns and objects, such as face5 (Fig. 1).
The M pathway projects to V3 and V5, directly
from V1 and through the thick stripes of V2. Most
cells in V3 are orientation selective and are believed
Fig. 2: Schematic diagram illustrating the location of the “what” and “where” pathways in the brain
Multifocal IOLs and Dynamic Vision 39
to be concerned with processing dynamic form. V5
is believed to process information on motion and
stereoscopic depth. Lesions of V5 cause deficits in
pursuit eye movements and in discriminating the
direction of motion. The M pathway then projects
to the parietal cortex. This area is important for the
integration of movement and depth into a
representation of space.
It is also interesting that blindsight patients are
able to localize a stimulus and discriminate
movement.6 The retina project primary to the LGN,
however, the retina also project to other structures,
such as the superior colliculus. Many of these
connections transmit information about the position,
size and movement of visual stimuli and it is believed
these connections may mediate the residual vision
found in blindsight.
There is a functional organization of the visual
information that is processed in the two broad
systems, the “what” system also called the ventral
system or the Parvo-pathway, which is concerned
with the identification of an object, and the “where”
system, also called the dorsal system or the Magno-
pathway, which is concerned with the relative spatial
position of an object (Fig. 2). The two streams project
to different prefrontal cortical areas. 7 The what
system project to the cortex of the inferior convexity
ventrolateral to the principal sulcus and the where
system projects to the dorsolateral prefrontal region.
40 Multifocal IOLs
The prefrontal cortex is an important region for
working memory.
Objects must compete for attention and pro-
cessing space in the visual system, and that this
competition is influenced by both automatic and
cognitive factors.8 The automatic factors are usually
described at pre-attention or “button-up” processes
and the cognitive factors as attentive or “top-down”
processes. Pre-attentive processes rely on the
intrinsic properties of stimuli in a scene, so the stimuli
that tend to differ from their background will have
a competitive advantage in engaging the visual
system attention and acquiring processing space, for
example, a ripe red apple will stand out against the
green leaves of the tree. The separation of a stimulus
from the background is called figure-ground
segregation. The cell’s receptive field seems to shrink
around the attended stimulus.
In summary, beyond striate cortex, there is a
substantial divergence of information through
projections to neighboring cortical visual areas,
which in turn send projections to numerous other
higher visual areas, and so forth. In addition to this
feed-forward distribution of information, there is
feedback (through reciprocal connections) from the
higher cortical areas to lower areas.
MOTION PERCEPTION AND DYNAMIC VISION
Movement perception seems to be mediated by the
M pathway. The M pathway projects to areas V3
and V5 and both project to the parietal cortex, where
a spatial representation of the environment seems
to be encoded. Most cells in V3 are orientation
selective and are believed to be concerned with
processing dynamic form and three-dimensional
structure from motion. Each V5 neuron responds
preferentially to a particular speed and direction of
motion and is responsible to our perception of global
motion.9
V5 seems to be divided into two subdivisions
that analyze different aspects of motion, which seem
to be related to two broad areas of function. These
subdivisions project to separate visual areas within
the parietal lobe; medial superior temporal (MST)
division l and d, (MSTl, MSTd). Neurons in MSTl
seem to be responsive to the motion of an object
through the environment, whereas neurons in MSTd
seem sensitive to motion caused by movement of
our eyes or of ourselves. Neurons in this latter area
are responsive to changes in certain parameters of a
stimulus, such as an increase or decrease in its size
(such as might be produced when tilting our heads)
and shear (such as might be produced when moving
past objects at different distances).10-12 In addition,
some cells are sensitive to mixtures of these stimulus
parameters, such as spiral motion patterns, which
have components of both rotation and expansion.3
In determining the nature of the movement of
an object or scene across the retina, the visual system
has to determine whether the eyes are moving, the
head or body is moving or the object itself is moving.
To determine whether the eyes are moving, it seems
that the cortical motor areas that control eye
movement simultaneously send a signal to the visual
system, is the corollary discharge theory.14
Under normal circumstances our eyes are
constantly moving and this is due to the organization
of the retina. High acuity color vision is limited to
the central two degrees of the visual field
corresponding to the fovea. Outside of this small
window the cones population decline by a factor of
about 30 as one move from central vision to 10
degrees of eccentricity.15 This concentration of the
central visual field is continued in the cortex. It seems
that despite our impression of a stable visual
image, our eyes are always moving, this allow all
or most of the features of a scene to be brought
into the high acuity center of the visual field. Our
visual image seems to be constructed by, (1) repeated
foveation of different objects, or parts of objects,
(2) the use of short-terms working memory of each
snap shot and (3) the predictive properties of the
visual system.16
When we fixate an scene, our eyes are not
absolutely still but make constant tiny movements
called microsaccades and occur several times per
second (random in direction and 1-2 min of arc in
amplitude). When we explore the environment, our
eyes do not move in smooth continuous movements.
Instead, our eyes fixed an object for a brief period
(500 msc) before changing to a new position in the
visual field. This rapid eye movement is called
saccades. Saccades can reach very high velocities,
800 dg/sec as their maximum and the size of this
movement is typically 12-15 degrees. Although a

saccade may be used to favor a moving stimulus,
the eye must somehow subsequently track the
stimulus at it moves through the visual field. This is
done using pursuit (smooth) eye movement with a
velocity of around 30 dg/sec. When the whole visual
scene moves, then a characteristic pattern of eye
movements occurs, called an optokinetic nystagmus
(OKN). A typical example is when we look out of
the window of a moving vehicle like a train. The
OKN has two components called the fast and the
slow phases. In the slow phase there is a smooth
pursuit of the moving field, which stabilizes the
image on the retina. If the velocities of the field
movement increase above 30 dg/sec, the eyes lag
progressively behind and the stabilization is less
effective. The slow-pursuit phase alternates with fast,
saccadic eye movements that return the eyes to the
straight ahead position. The OKN seems to be a
primitive form of eye movements control designed
to prevent displacement of the retinal image during
locomotion.
During rapid eye movements we will not be
conscious of a visual “smear” caused by the move-
ments of the image across the retina. The answer is
that some form of suppression of the signal from
the eye occurs when it makes a saccade. This suppres-
sion of perception seems to be confined to the M
pathway.17
Neurons in V5 are sensitive to the speed and
direction of moving objects, and each neuron has a
preferred direction of motion that stimulates its
maximal response. Many of these neurons are
inhibited by motion in the opposite direction, and
this inhibition is believed to help reduce noise and
ensure an accurate representation of the moving
stimulus. This explains why the brain has no
difficulty in distinguishing objects in the visual field
that are constantly passing in front of one another.
MULTIFOCAL LENS AND DYNAMIC VISION
The visual performance of patients who have
undergone cataract extraction depends on the type
of IOL that has been implanted. Monofocal IOLs
provide excellent visual function, but, for many
patients, their limited depth of focus means that they
cannot provide clear vision at both distance and near.
Multifocal IOLs and Dynamic Vision 41
If the monofocal IOL power is selected for distance
correction, reading spectacles will be required.
Recently, multifocal IOLs have been developed
that offer the pseudo-phakic patient the possibility
of satisfactory vision at both distance and near
conditions without the use of spectacles 17-24 however
the use of multifocal IOLs has been very limited in
the past because of several drawbacks and
limitations. Surgical techniques were not as refined
as they are today, and predictable and accurate
biometry to achieve emmetropia was challenging,
moreover the photic side effects as glare and halos
was an important problem (Fig. 3).
Nowadays the new IOL designs were engineered
to minimize photic phenomenon and to have a lower
incidence compared with previous multifocal lens
designs and at the same time there will be a
neuroadaptation phenomena that should explain
why only 16% spontaneously reported glare and halo
in one multifocal study, whereas 40 to 50% of these
same patients noted these side effects on active
questioning compared with 13 to 20% of patients
with a monofocal IOL. 25 Neuroadaptation is an
Fig. 3: Schematic diagram showing a multifocal lens with
the two principal focus near-far (A). The brain has to select
the appropriate focus for each object, which implies a
neuroadaptation process. When a distant object is viewed,
a sharp retinal image is provided by those parts of the lens
within the pupillary area that have the distance correction
and a blurred image is provided by the other parts of the lens
(near and intermediate), these images are superimposed
on the retina generating a diffusion halo (B), that could impair
visual quality and contra-sensitivity, more intense in scotopic
conditions than in photopic, 85, 5, and 2.5 candelas per
square meter (cd/m2), respectively
42 Multifocal IOLs

important fact because the new strategies try to
combining different types of multifocal lens to obtain
an overall vision, like “Mix and Match”, with a
diffractive lens in one eye, for better distance and
near vision and a refractive lens in the other eye,
for better distance and intermediate vision. IOLs
with different reading capabilities induce brain shifts
to focusing between both eyes. This continual
intraocular contest for visual awareness is binocular
rivalry at work and could impair vision capabilities.
There are several studies demonstrating good visual
acuity and no significant reduction in contrast
sensitivity with multifocal lens, but there is no
studies analyzing dynamic vision.
Dynamic and motion perception are important
factors of our vision, absolutely necessary in outdoor
life, especially for driving, sports and many others.
To analyze the impact of multifocal lens upon
dynamic vision we have conducted different
studies, trying to represent real life situations. A
paradigmatic example should be to catch a moving
object where it is necessary to track and pursuit the
object and adapt our hand movements to the exact
position to catch the object in the precise position
any time. This example supposes two main visual
abilities, (1) fix and pursuit the moving object and
(2) a neural retardation of the object perception to
calculate the exact position to be cached. If multifocal
lenses don’t affect dynamic vision, the results will
be similar to the results obtained in a normal
population. For this reason we have selected two
different tests, the “screening pursuit test” and the
“flash-lag effect”, one to study the pursuit
phenomena and the other to study the neural moving
retardation.
The tests were performed to 46 patients divided
into four groups with similar demographic
characteristics. All the patients were pseudophakic,
with no complications or ophthalmic pathology that
could influence the results. The studied population,
of both sex, age rate from 52 to 68 years (55. 8 + 7.3),
and preoperative ametropia between +3 and -4
(spheric equivalent). The tests were achieved after
an evidence of vision stability between 6 months
and 1 year postoperative. The groups of patients
correspond to different intraocular implants. Group
1, with 12 patients, were treated with monofocal
lenses (Clarifex, AMO) looking for emmetropia.
Group 2, with 10 patients, had implants of monofocal
lenses (Clarifex, AMO), looking to avoid the use of
glasses by means of monovision, emmetropia, in the
dominant eye, and a target of -2.5 in the non-domi-
nant eye. Group 3 (12 patients), were implanted
multifocal refractive lenses ReZoom (AMO) in both
eyes. The patients of Group 4 (12 patients), were
treated with the strategy of “Mix and Match”,
implanting a Rezoom lens in the dominant eye, and
a diffractive Tecnis lens (AMO) in the non-dominant.
All of the patients reported a spontaneous binocular
visual acuity equal or superior to 0.8 for far vision,
and J3 for near vision, except the patients of G1 with
monofocal lens and focus for far vision that required
optical correction for near vision to reach a minimum
of J3.
FLASH-LAG EFFECT
When a moving and a flashed stimulus are physically
aligned in space and time, observers usually perceive
the moving stimulus ahead of the flashed stimulus.
This situation is known as the flash-lag effect (FLE)
or flash-lag Illusion26,27 (Fig. 4).
Fig. 4: Representation of the effect Flash-lag. (A) shows the
real situation, one white circle in movement from where a
flash is projected, that consists in a red line located in front
of the medium line of the circle. (B) represents what the
subject sees, the red line is perceived with delay respect to
the reality shown by (A) The graphic on the left shows the
typical curve of normal subjects (violet) that compared to
subjects with dynamic vision alterations (green), it does not
appear the position delay of the red line
 Multifocal IOLs and Dynamic Vision 43

Several explanations for this simple illusion have

been explored in the neuroscience literature, but the
most accepted explanation for the flash-lag effect is
that the visual system is predictive, accounting for
neural delays by extrapolating the trajectory of a
moving stimulus into the future.27,28 In other words,
when light from a moving object hits the retina, a
certain amount of time is required before the object
is perceived. In that time, the object has moved to a
new location in the world. The motion extrapolation Fig. 5: Flash-lag study. The histograms show the percentage
hypothesis asserts that the visual system will take value with respect to the normal population that would
correspond to 100% value. Group-1, with monofocal lenses
care of such delays by extrapolating the position of for far vision and correction for near, reports the closest value
moving objects forward in time. to the ideal one, 92.3%. While, Group-2 treated with
The proposed experimental design is that used monovision, one eye for far vision and the other for near, it’s
by Maiche, Budelli and Gómez-Sena 29 in their the group that reports more alterations, 64.7%. The groups
experiments: each trial begins with a fixation point with multifocal lenses, Group-3 with the same lens in each
eye, as Group-4 treated with Mix and Match with different
on the central area of a screen. This appears at
reading capacity, show similar results than normality, 89.2
random position in each trial within the range of 1º and 87.5, respectively
in order to prevent the use of distance between the
fixation point and the flash as a cue to solving the
with the patients of the G3 and G4, with multifocal
task. The ring (external diameter: 5.8º and width 1º)
refractive lenses in both eyes, and the combination
emerges from the left border, passes horizontally
of lenses, diffractive and refractive, respectively,
across the screen at a constant speed of 35º/s and
showed similar results, without any evidence of
disappears through the right border. Once the ring
significant changes, as it occurred with the patients
has passed the fixation point, a red vertical line
of group 2 with strategy of monovision. In this last
(subtends 7.2º in length and 0.06º width) is flashed
case, despite the near-intermediate vision, without
over the ring for one single frame (11.7 ms) in one
correction, was superior to J3, which allows
of seven different horizontal positions.
spectacles independence for far and near vision; it
At the end of each trial, the subjects must answer
reported a worsening during the flash-lag test. The
to the question “is the flash ahead of the half ring?”.
patients with monovision did not report the delay
The proportion of answers “yes” it’s a function of
that appears under normal conditions. It occurs the
the time it will take the middle of the ring to reach
same anomalous situation than the corresponding
the position of the flashed bar. Each group of data
to the test of pursuit, which we will analyze next.
were fit with logistic functions to derive the Point
of Subjective Equality (PSE), which indicates the
PURSUIT ANALYSIS
“distance” required by the subject in order to
perceive the flash line exactly in the middle of the The Screening Pursuit test, it is running from a
ring (Fig. 4). computer Dell Precision 390 Intel Pentium Extreme
The results of the study (Fig. 5), show significant edition, 2.67 Ghz. This computer provided with
differences in the monovision Group 2. The G1, keyboard and complementary CRT monitor to checks
considered the control group, evidenced a delay of up on the subjects execution, is also connected to an
the flash-lag similar to the ones referenced in Eye Tracker provided with a 17” TFT monitor,
literature for phakic normal subjects;26-28 that is, the screen resolution of 1280 x 768 pixels, and refreshing
pseudophakic situation, inclusive needing of optical frequency of 100 Hz. This monitor has integrated
correction for near-intermediate vision, does not with the frame the infrared light-emitting diodes,
suppose a negative factor to this phenomenon of hidden in its upper and lower part, thus unnoticed
neurological adjustment, flash-lag, so necessary for to the users, and it is also provided with a camera
the real life. In the same way, the values obtained of high resolution, with frequency of 50 Hz, it is
44 Multifocal IOLs
Fig. 6: The image illustrates how the test is performed. The
patient located in front of the screen, and the eye tracker
integrated to the system (blue and red lines) that helps to fix
the eyes and adjust the distance to proceed with the
registration of the ocular movements during the test, and
then to process them for further analysis
located at the center of the lowest part of the monitor
(Fig. 6).
The fixation point is positioned right in the center
of the monitor; the users are placed at a 45 cm of
distance; thus achieving, a visual field evaluation of
41º of eccentricity, in horizontal axe and 33º in vertical
axe.
The Screening Pursuit test is executed in binocular
vision and consisted of 6 training trials followed by
48 experimental trials. The administration time is
two minutes approximately, depending on the
reaction time of every subject.
Each trial started with a fixation point (static cross)
projected in the middle of the screen (position (0,
0)) on a grey background (60 cd/m2) during 400 ms.
Following the point a circle of 0.78 cm size, black
color (0,1 cd/m2) appears. The circle can move in a
varied of randomly angles (45º, 90º, 135º, 180º, 225º,
270º, 305º, 360º), making possible the randomized
variant depending on the three possibilities, linear,
right parabola or left parabola). The stimulus will
move at a constant speed from the center to a position
of 7.9º with 10º/sec speed and 7.0º with 20º/sec
(randomized variation), analyzing two different
eccentricities, 20º and 40º.
Right after the cue appears, a circle to the same
features and the mentioned above, but with a 150
cd/m2 luminance and 100 msec duration. Immediately
after the target appears an equilateral triangle with
the vertex up or down (semi-randomize in a
proportion of 1/1) with a duration of 160 msec. As
soon as the target appears, the subjects react as quick
and accurate as possible. This is a closure response
with two choices, corresponding to 2 keys of the
keyboard: up or down direction. Once the response
is registered the trial will remain on the screen up
to 200 msec (PRI: post response interval).
The test was performed to the group of patients
above mentioned, following the methodology just
described. The results are shown in Figure 7,
illustrating a similar situation than the one obtained
with the flash-lag test. Same than G1, with implant
of monofocal lenses with principal focus for far
vision, considered the control group, as the results
are similar to the previously published for normal
subject. Once again, it is evidenced the difference
between the group 2 with monovision strategy, and
the groups 3 and 4 with multifocal lenses. In group
2 there is a reduction of the 30 percent of the pursuit
capacity, this value maintain almost stable in the
eccentricities used in the study (20º and 40º), while
in the patients treated with multifocal lenses, there
is no reduction. In group 3, with ReZoom lenses in
Fig. 7: Screening pursuit test. The histograms show the final
results expressed with a 0 to 1 index. (1) corresponds to the
value of the normal population. The Pursuit test was
performed in two levels of stimulus eccentricity, 20º and 40º.
Both situations show that Group-2, with monofocal lenses
and monovision strategy, reported the worst results.
Whereas, the rest of the groups, reported results close to
the 100 percent, highlighting Group-4, with Mix and Match
treatment, that reported better results

both eyes, the results are slightly lower to the group
1, with no significant differences. However, in the
group 4 treated with Mix and Match, results are again
superior to control group 1 (P < 0.03), a difference
fairly significant, but that evidences that these
patients tended to adjusting to the external environ-
ment, similar or superior to the one achieved with
conventional monofocal lenses.
This makes clear, that the monovision strategy
with monofocal lenses, despite the patients tolerance,
is not the best solution to solve the problem for near-
intermediate vision after crystalline surgical treat-
ment, as the dynamic vision of these patients is
altered, with consequences in situations as driving,
or working activities of risk, that require a good
dynamic vision.
These results are very significant because, despite
mishaps of dysphotopsias, halos and glare, that may
present the multifocal lenses, it is the first time that
good results were evidenced in a motion test, even
something superior in the group of patients treated
with Mix and Match that, let’s recall, present different
focus for each eye. This fact is explained by making
reference to the mechanism of visual perception that
the brain uses, a sort of multifocality by which it
selects by ovation the part of the visual field most
interesting, to “see” in great detail the components.
Because of this, the fact of a vision as offered by the
multifocal lenses, inclusive when they are different,
as in the case of the Mix and Match, more than an
inconvenient, it is an advantage, from the practical
point of view in dynamic vision. Further investi-
gations will be needed to clarify in depth all these
aspects.
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13. Graziano MSA, Andersen RA, Snowden RJ. Tuning of
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 6
Improvement of Visual Function
with Training after Multifocal
Intraocular Lens Implantation
CATEGORY
Clinical investigation.
KEYWORDS
Multifocal intraocular lenses, perceptual learning,
neural adaptation, contrast vision, visual training. The
authors have no commercial or proprietary interest
in the products or companies mentioned in this paper.
ABSTRACT
Purpose: Several studies showed that after multifocal
intraocular lens (MIOL) implantation visual function
improves gradually over a period of several months.
To accelerate this learning process we performed a
prospective, intraindividually comparing study to
investigate the efficacy of a special visual training
program on the postoperative visual performance.
Material and methods: Sixteen patients with bilateral
phacoemulsification and MIOL-implantation in both
eyes (8 with the Alcon Restor, 8 with the AMO Tecnis
ZM900) received a computer based visual training 6
weeks postoperatively based on the concept of
perceptual learning of discrimination line orien-
tations. The training was performed over two weeks
in 6 sessions with one eye of each patient. The
untrained fellow eye served as control. Before and
after the training period and after 6 months the
following functions were assessed: Orientation visual
acuity (OVA), distance VA, contrast sensitivity, and
near VA for different contrast levels.
Hakan Kaymak, Ulrich Mester
Results: After two weeks of training, the mean
improvement of OVA in the trained eyes was 82%,
being significantly higher than the control eyes (p <
0.001). Also contrast sensitivity and near vision under
different contrast levels showed a significant benefit
of training. The superior function of the trained eyes
was still present at the 6 months control.
Conclusion: Visual performance after MIOL-
implantation can be significantly accelerated by a
specific training program within two weeks. This
effect is sustained at least over a 6 months period.
Purpose
A new generation of MIOL with improved optic
design allows a high percentage of those patients
implanted with MIOLs being free of spectacles
postoperatively. Therefore MIOLs receive increasing
interest and acceptance.1,2
On the other hand, clinical studies showed that
visual function after MIOL-implantation needs up to
several months to reach its maximum.1,3,4 Obviously,
a learning period is required for patients to tolerate
simultaneous vision of two images, reduced contrast
and decreased edge distinction, which are side effects
of the double focus optical system.5
From psychophysical experiments we learned
that, due to neural plasticity present even in adults,
visual learning leads to sometimes dramatic and quite
fast improvement of performance in perceptual
tasks. 6,7 We therefore investigated the effect of a
special training program on visual performance after
MIOL-implantation.
48 Multifocal IOLs
Materials and Methods
In a prospective, non-randomized, and intra-
individually comparing study 16 patients received
bilateral uneventful phacoemulsification with MIOL-
implantation by a single surgeon (UM). All eyes
showed no pathology with the exception of cataract.
Both eyes were operated on within one week. In eight
patients the Restor MIOL (Alcon) was implanted in
both eyes, the other eight patients received the Tecnis
ZM900 (AMO). Patients’ demographics are presen-
ted in Table 1.
Before commencing the visual training 6 weeks
after surgery, informed consent was obtained from
all patients after the nature of the procedure had been
fully explained. After determing the dominant eye of
the patients the training was performed on the
nondominant eye. The untrained fellow eye served
as control.
Before and the day after the training program and
after 6 months additionally to biomicroscopy of the
anterior and posterior segment the following
functions were assessed for both eyes:
• Orientation visual acuity (OVA) (Parameter
Estimation by Sequential Testing, PEST)
• Distance visual acuity (VA) (ETDRS-charts)
• Near VA for different contrast levels: 100%, 25%,
12.5% (CAT Stereo Optical Comp., Chicago, Jll,
USA)
• Contrast sensitivity (FACT Ginsburg Box, Model
CS 1800 D, Stereo Optical Comp, Chicago, Jll,
USA) under photopic 85 cd/m2, mesopic 6 cd/
m2, and mesopic with glare conditions was
calculated as area under the curve (AUC).
Table 1: Patients´demographics
Tecnis Restor
Age (years) 69±3 71. ± 9
Lens power (diopters) 21.8 ± 1.7 22.3 ± 3.9
Sphere (diopters) 0.2 ± 0.3 0.0 ± 0.1
Cylinder (diopters) 0.3 ± 0.3 0.24 ± 0.3
Spherical equivalent (diopters) 0.0 ± 0.3 -0.1 ± 0.2
Training Method
The procedure is based on orientation discrimination
of tilted bars which are presented on a monitor.
Observers sat at a fixed distance of 1m from a
Samsung LCD 19” Monitor (1280 × 1024 resolution,
75 hertz) that was controlled by a personal computer.
Test stimuli consisted of thin (1 arcmin wide) bright
lines, presented on a dark surround. The length of
the test stimulus was 50 arcmin and presentation time
was 500 ms. After a 300 ms pause after each stimulus
presentation the request to decide was presented.
After decision (via push button) the next stimulus was
presented. Observers had to indicate in a binary
forced-choice task without time pressure whether the
stimulus was slightly inclined to the left or else to the
right (for vertical stimuli), or whether the left or right
end was lower relative to the other end (for horizontal
stimuli). Decision was indicated by pushing either the
left or right of two push buttons. Training consisted
of 6 sessions during 2 weeks: 7 blocks with 50 stimulus
presentations each had to be fulfilled in each session.
Mean time of sessions was 30 min ± 5 min. Only one
session per observer took place each day, with
sessions following each other in intervals of no longer
than 3 subsequent days.
Assessment of OVA
The staircase procedure8 controlled the orientation
difference between the stimuli presented to each
patient before and after training (orientation visual
acuity, OVA). Thresholds were defined as 75% correct
responses. The individual OVA was measured in
arcmin, which defines the minimum angle of the
inclined stimulus (either right or left) the observer was
able to discriminate, relative to a fully vertical or
horizontal line.
Statistics: Two-sided paired t-tests were applied, with
a level of significance of p < 0.05.
Results
All 16 patients passed the complete training program
and the pre- and post-training examinations.
Eight patients received the Restor MIOL
bilaterally, eight the Tecnis MIOL as indicated above.
Postoperatively all eyes showed clear optic media,
no visible decentration or tilt of the intraocular lens
 Improvement of Visual Function with Training after Multifocal Intraocular Lens Implantation 49

(IOL), and a mean capsulorhexis size of 5.3 mm with

circular overlap of the rhexis rim. Fundus examination
did not reveal any pathology such as cystoid macular
edema. Patient demographics and postoperative
refraction are summarized in Table 1.
The functional tests, performed immediately (1
day) after finishing the training program showed a
highly significant improvement of OVA (82 %) for
the trained eyes for bars presented in the trained
orientations (vertical) (p = 0.001). The fellow eyes
Fig. 2: Scatter plot of the relation of individual OVA improve-
showed only a slight (9 %), insignificant improve- ment and pre-training OVA including r value of correlation
ment. Testing OVA with bars in the non-trained axis (Pearson correlation)
(horizontal) revealed only a slight improvement (4
%) without statistical significance. This situation was
nearly unchanged at the 6 months control (Fig. 1).
Comparing the individual improvements of OVA
testing through training to the pre-training OVA
shows that the greatest benefit is gained in the eyes
with the lowest OVA (Fig. 2). Distance VA was
slightly but not significant better in the trained eyes
after training at the end of the training (Table 2). Six
months after training BCVA hat improved in both
eyes. This improvement was statistically significant Fig. 3: Change of mean BCVA measured using high contrast
(p < 0.05)for both eyes (Fig. 3). The difference of ETDRS charts in trained eyes (yellow) and control eyes (red).
distance VA between trained and control eyes was Means and SDs of 16 eyes ( ***= p<0.001; **= p<0.01 *=
significant (p < 0.01) in favor of the trained eyes p<0.05; n.s.= not significant)
(Table 3).
Near VA was significantly better for 100 % (+7 significant improvement (+10 %) only for the lowest
%), 25 % (+15 %) and 12.5 % (+24 %) contrast after contrast level at the first control (Fig. 6), being also
training (Figs 4 to 6). The control eyes showed a significantly inferior to the gain of the trained eyes
(Table 2). These results proved to be stable also after
6 months (Table 3).

Table 2: Comparison of visual acuity between trained

and control eyes immediately after training end
Training end
Trained eyes Control eyes Significance
(reading (reading level
letters) letters)

100% contrast 50 ± 8 48 ± 8 p=0.06

Distance VA
100% contrast 65 ± 8 60 ± 6 p<0.05
Near VA
Fig. 1: OVA for horizontal bars had improved in the trained 25% contrast 44 ± 6 40 ± 5 p=0.07
eyes but not in the untrained eyes, also OVA for horizontal Near VA
bars showed in the trained eyes no improvement after training
12.5% contrast 42 ± 5 39 ± 7 p<0.01
end. Means and SDs of 16 eyes ( ***= p<0.001; *= p<0.05;
Near VA
n.s.= not significant)
50 Multifocal IOLs

Table 3: Comparison of visual acuity between trained and

control eyes 6 months after training

6 months after training

Trained eyes Control eyes Significance
(reading (reading level
letters) letters)

100% contrast 56 ± 5 53 ± 5 p < 0.01

Distance VA
100% contrast 67 ± 6 63 ± 8 p < 0.01
Near VA
25% contrast 43 ± 6 39 ± 7 p < 0.01 Fig. 6: Change in mean uncorrected near contrast visual acuity
Near VA (12.5%) in trained (yellow) and control eyes (red). Means and
12.5% contrast 40 ± 6 37 ± 6 p<0.01 SDs of 16 eyes. ( ****= p<0.00001; **= p<0.01; n.s.= not
Near VA significant)

The improvement in contrast sensitivity under

Fig. 4: Change in mean distance-corrected near contrast
visual acuity in trained (yellow) and control eyes (red). Means
and SDs of 16 eyes. ( ****= p<0.00001;*** p<0.001; **= p<0.01;
*= p< 0.05; n.s.= not significant)
different conditions (photopic, mesopic, and mesopic
with glare) was only significant in the trained eyes at
the training end (Figs 7 to 9). The superiority of the
trained eyes was also still present after 6 months
(Table 4).
The course of OVA during the training period
reveals that the largest greatest improvement occurs
within the first 3 sessions (Fig. 10). The functional
outcome of the eyes with the Restor MIOL was not
significantly different from the eyes with the Tecnis
MIOL.
Discussion
In contrast to the postoperative course after
monofocal IOLs, visual function after MIOL

Fig. 5: Change in mean distance-corrected near contrast Fig. 7: Change in contrast sensitivity under photopic conditions
visual acuity (25%) in trained (yellow) and control eyes (red). calculated as mean of the area under curve (AUC). Means
Means and SDs of 16 eyes. (*** p<0.001; **= p<0.01; n.s.= and SDs of 16 eyes. ( ***= p<0.001; n.s.= not significant)
not significant)
 Improvement of Visual Function with Training after Multifocal Intraocular Lens Implantation 51

Fig. 8: Change in contrast sensitivity under mesopic conditions

calculated as mean of area under curve (AUC). Means and
SDs of 16 eyes. ( ***= p<0.001; *= p<0.05; n.s.= not significant) Fig. 10: Orientation VA (arcmin) versus number of 6
sessions within 2 weeks. Means and SDs of 16 eyes

implantation needs up to several months to reach

it’s maximum.1,3,4 This may be explained by the loss
of contrast at both focal points: the reduced amount
of light that is creating the distance focus as well the
overlying out-of-focus near image impairs the
contrast sensitivity and near contrast visual acuity.
The experience that these functions improve over
time motivated us to train the visual system since
improvement should rely on cortical rather than
optical improvements.
Fig. 9: Change in contrast sensitivity under mesopic with glare In the neurobiological literature we found a large
conditions calculated as mean of the area under curve (AUC). fundus of reports dealing with practicing visual tasks,
Means and SDs of 16 eyes ( ***= p<0.001; **= p<0.01 *= leading through of a process termed “perceptual
p<0.05; n.s.= not significant) learning”, to a significant improvement in perfor-
mance. Perceptual learning is defined as any
relatively permanent changes of perception (usually
Table 4: Comparison of contrast sensitivity calculated improvement as measured by changes in perceptual
as area under curve (AUC) between trained and control thresholds or brain physiology) as a result of
eyes after training end and 6 months experience.7
Trained eyes Control eye Significance One of the tasks employed most often to test
Area under Area under level perceptual learning is visual hyperacuity. Several
curve curve hyperacuity tasks such as vernier discriminations
(log CSF*c/deg)(log CSF*c/deg) were shown to improve with practice in both adults
Training end with normal vision 6,9 and adult amblyopic
Photopic 22.1 ± 4.5 20.0 ± 5.0 p < 0.005 patients. 10,11 It could be shown that VA could be
Mesopic 17.9 ± 3.2 15.7 ± 4.0 p<0.050 improved while practicing a very different and
Mesopic with 16.2 ± 5.0 13.3 ± 2.1 p < 0.006 functionally more basic task using stimuli
glare 6 months differenting from those used for the acuity tests.
after training Improving the early processing in the visual system
Photopic 22.7±5.0 19.9 ± 4.0 p < 0.05 resulted in an improvement of all higher levels of
Mesopic 19.8±3.7 17 ± 3.4 p < 0.02 processing that depend on the quality of the low-
Mesopic with glare 17.3 ± 4.2 15.4 ± 3.5 p < 0.05 level visual representation.9
52 Multifocal IOLs
Such a low-level feature of the stimulus is
orientation discrimination using tilted bars,7 which
was used in our study. Our results confirm the finding
of previous studies7,9,12 that OVA can be improved
by training using orientation discrimination without
interocular transfer. The improvement did neither
transfer to another task, as there was no significant
change in the trained eyes for the non-trained
stimulus orientation (horizontal).
Another interesting finding is the correlation of
OVA improvement with the pre-training OVA: The
lower the OVA before starting the training program
the greater the gain in visual performance. Although
being statistically significant this evaluation
demonstrates a high interindividual variability of
OVA (Fig. 2).
A major question is the impact of OVA-improve-
ment by training on visual function as assessed with
visual acuity test (ETDRS, CAT 100%). While distance
VA showed a slight, non-significant improvement
after training the difference became significant at
the 6-months control (Fig. 3). Near vision was
significantly better compared to the control eyes
(Fig. 4 and Tables 2 and 3) at all visits.
One major drawback of MIOL is impaired contrast
vision.13 We therefore paid particular attention to the
impact of the training with orientation discrimination
on contrast vision. The influence of a training with
orientation discrimination seems to be stronger on
contrast vision than on visual acuity: Looking to
contrast measurements using the CAT-charts the
gain by training became more evident with decreasing
contrast (25%, 12.5%) after the training (Figs 4 to 6
and Tables 2 and 3).
Also contrast sensitivity under different lighting
conditions revealed significantly better results. These
findings are in agreement with results published by
Matthews et al.14 Examining normal adult humans
they found that contrast sensitivity improved
significantly after observers demonstrated practice-
based increases in orientation discrimination. Several
other investigators demonstrated a significant
impact particularly on contrast vision after vernier
task training in amblyopic eyes. 10,12 Polat et al 9
documented a 2-fold improvement in contrast
sensitivity in adult amblyopes following training of
Gabor detection (bars with blurred edges). Training
of basic psychophysical tasks improves processing/
coding of basic visual features that in turn facilitate
performance in the high level visual acuity task, while
training of VA may not have allowed direct access to
some of the basic visual features, was also postulated
by other authors.15,16
All functional results were not significantly
different for the two MIOLs investigated. As the two
lenses were unequal in optic design this finding
supports our assumption that the effect of perceptual
learning is not due to a specific design of MIOLs but
due to the basic nature of MIOLs with the simul-
taneous presentation of two images on the retina. A
fundamental question concerns the persistence of the
training effect found immediately after training
period. The reinvestigation after 6 months showed
almost unchanged OVA-values and near VA for
different contrast levels. Distance BCVA was
significantly raised in both, the trained and the
untrained eyes, but significantly better in the trained
eyes. This is according to the initially mentioned
observation that VA increases over a longer time
after MIOL-implantation. Interestingly, contrast
vision showed the greatest impact of training under
all lighting conditions whereas the untrained eyes
showed only a slight improvement. The training
demonstrated the largest gain of contrast vision
between the beginning and the end of the training
program with a slight further improvement at the 6-
months control. Contrast vision in the fellow eyes was
almost unchanged to the pre-training values after 6
months under photopic conditions and slightly
improved under mesopic and mesopic with glare
measurements. These data support findings of Zhou12
and Polat et al9 who found an excellent retention of
the training effect up to one year post-training.
Another question is, how much training is needed
to improve visual function? Our training program
consisted of 6 sessions within 2 weeks. The assessment
of OVA at each session revealed the greatest gain after
the first 3 sessions (Fig. 10). From a practical point of
view it might be possible to shorten the training
program after MIOL-implantation.
Finally, one may speculate that such a training
could be suitable to diminish the perception of halos
by improved suppression of the second, blurred
image being constantly presented on the retina due
 Improvement of Visual Function with Training after Multifocal Intraocular Lens Implantation
to the bifocal optic design of MIOLs. Further
investigations will try to answer these questions.
REFERENCES
1. Mester U, Hunold W, Wesendahl T, Kaymak H.
Functional outcome after implantation of the Tecnis
multifocal intraocular lens ZM900 compared to the Array
SA40. J Cataract Refract Surg (In press).
2. Kohnen T, Allen D, Boureau C, Dublineau P, Hartmann
C, Mehdorn E. European multicenter study of the
AcrySof Restor apodized diffractive intraocular lens.
Ophthalmology 2006; 113:578-84.
3. Montés-Micó R, Alio JL. Distance and near contrast
sensitivity function after multifocal intraocular lens
implantation. J Cataract Refract Surg 2003;29:703-11.
4. Petermeier K, Szurman P. Subjecitve and objective
outcomes following implantation of the apodized
diffractive AcrySof Restor. Ophthalmologe (in press).
5. Steinert RF. ASCRS Binkhorst lecture 2004: the search
for perfect vision: Ophthalmology´s Holy Grail ? J
Cataract Refract Surg 2005;31:2405-12.
6. Fahle M, Edelman S, Poggio T. Fast perceptual learning
in visual hyperacuity. Vision Res 1995;35:3003-13.
7. Fahle M. Perceptual learning: A case for early selection.
Journal of Vision. 2004;10:879-90.
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8. Taylor MM, Creelman DC. PEST: Efficient estimates on
probably functions. The Journal of the Acoustical Society
of America. 1967;41:782-7.
9. Polat U, Ma-Naim T, Belkin M, Sagi D. Improving vision
in adult amblyopia by perceptual learning. Proc Natl
Acad Sci USA. 2004;101:6692-7.
10. Levi DM, Polat U. Neural plasticity in adults with
amblyopia. Proc Natl Acad Sci USA. 1996;93:6830-4.
11. Levi DM, Polat U, Hu YS. Improvement in vernier acuity
in adults with amblyopia. Practice makes better. Invest
Ophthalmol Vis Sci 1997;38:493-1510.
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Perceptual learning improves contrast sensitivity and
visual acuity in adults with anisometropic amblyopia.
Vision Research 2006;46:739-50.
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multifokaler Intraokularlinsen. Ophthalmologe
2007;104:236-42.
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 7
Eyemaginations
INTRODUCTION
The focus of this chapter is to introduce cataract
surgeons to a suite of products and how these
products may help to improve the patient education
process for presbyopia-correcting intraocular lens
(IOL) surgery.
PATIENT EDUCATION
What do patients want to know? Eyemaginations
asked this question ten years ago—before it deve-
loped its “3D-Eye Office” patient education software
system—and discovered that most patients want
answers to four basic questions:
1. What problem(s) will the doctor find?
2. What treatment options are available for the
problem(s)?
3. What is the cost of treating the problem(s)?
4. Is there a correlation between the premium
options and the surgical outcome?
As a cataract surgeon, ask yourself how you
handle these questions in your clinic. What do you
do to help your patients understand the risks they
face? How do you help them to understand the
advantages, disadvantages, risks and benefits of all
available treatment options? How do you help them
to understand the financial implications of treatment
plans that may not be covered by insurance? How
do you help them to set their expectations
appropriately in the context of their lifestyle needs,
professional needs, age, or overall health?
Educating patients about their options for
presbyopia-correcting surgery can be particularly
Joe Boorady, Brad Soper
difficult. Patients need a basic understanding of
presbyopia before they can understand any of the
treatment options and the perceived complexity of
the treatment options can prove overwhelming to a
layperson. The patient education technologies
developed by Eyemaginations can make this
educational task much easier for both doctors and
patients.
Why 3-Dimensional Animation?
Doctors, who are familiar with anatomy and medical
terminology, can easily derive meaning from written
text on 2-dimensional drawings. Patients, however,
can find written descriptions of medical subjects
tedious or confusing and often lack the anatomical
context to derive meaning from 2-dimensional
drawings. In a research study published in 2002, Dr.
Michael Hermann, of the University of Vienna,
proved the value of using 3-D animation in patient
education. He conducted a prospective, randomized
comparison 3-D animation and written text used to
educate patients about a surgical procedure. He
concluded that “understanding of and subjective
knowledge about the surgical procedure and possible
complications, the degree of trust in professional
treatment, (and) the reduction in anxiety and
readiness for the operation were significantly better
after watching computer animation than after reading
text.”1 (Figs 1A, B and 2).
In 2006, a similar study on the “advantages of
interactive 3-D computer animation technology in
the demonstration of complex ophthalmological
subjects” was performed by Drs Carl Glittenberg
58 Multifocal IOLs

A B

Figs 1A and B: Eye examination (A) Examination by watching computer animation, (B) Astigmatism

and Susanne Binder. They found that ophthalmology

students who were taught using 3-D animation
understood complex subject matter better than those
who were taught via lectures or written text. “We
conclude that 3-D computer animation technology
can significantly increase the quality and efficiency
of the education and demonstration of complex
topics in ophthalmology,” they wrote.2
Eyemaginations has built its business and
reputation on providing cataract surgeons with
educational and marketing tools that feature high
quality 3-D animation. We agree that the most
effective way to educate patients about refractive
IOL surgery options is with animated 3-D computer
simulations.
Fig. 2: Cataract nucleus
THE 3D-EYE OFFICE PROGRAM in acuity and contrast caused by cataract, a summary
The 3D-Eye Office program enables the doctors and of the ways in which cataracts can interfere with a
staff in practice to access a number of complete patient’s lifestyle, a non-threatening depiction of
patient education programs with the push of a single cataract surgery via phacoemulsification, and a
button. The technology allows a practice to review of IOL options (Figs 3 and 4).
customize programs, save them, and access them A different menu of programs can be designed
using the function keys (“F” keys) on any computer for patients in the reception area of a practice.
keyboard. Practices can benefit from presetting a Information that creates a general awareness of
number of programs for use in the examination area, refractive procedures or other elective surgery or
including topics such as anatomy of the eye, of premium products and services are well suited to
refractive errors, cataracts; Practices should consider the reception room. For example, a continuous “loop”
having preset explanations on topics such as anatomy of animations explaining the advantages of multifocal
of the eye, refractive errors and cataracts. The wide or toric IOL’s, or of astigmatic keratotomy, can
variety of cataract segments available include a increase a patients’ awareness and interest in newer
patient’s point of view of the cloudiness and decrease cataract surgery technologies and motivate them to
 Eyemaginations 59

Fig. 3: Cataract POV Fig. 4: Cataract light scatter

ask you or your staff about these advances. patient an orientation image of a head, and then
Eyemaginations’ system combines responsible, rotate the head 90 degrees to help the patient
professional educational messages with 3-D understand the cross-sectional view they are about
animation that engages and captivates and entertains to see. You can draw on the image and explain how
patients while making medical information easy for the aging lens begins to interfere with close vision
them to understand. in the presbyopic age group. You can simulate the
Some clinics will look to use DVD technology to opacification of the crystalline lens in older patients
play patient education information in their reception as you describe how cataracts develop. This entire
areas. However, DVD technology is considered communication can be accomplished in less than 30
“static” technology and does not allow the infor- seconds (Fig. 5).
mation to be readily updated, personalized or Patients will be able to understand their specific
customized to each individual practice. Easy updating problem and possible treatments while the physician
and personalization is only achievable using the is right there. Content is important, but a quick,
“dynamic” technology of computer software-driven efficient, effective medium to deliver that content is
programming. The 3-D Eye Office system by equally important. The ability to draw right on the
Eyemaginations allows a practice to use this dynamic
technology in the reception area.
In the examination room, patients need
information more directly suited to their particular
eye conditions and with more physician involvement.
Animation-based information enables the physicians
to demonstrate eye anatomy, eye disease,
progression of eye disease, and treatment in a way
that is easy for patients to understand. The 3-D Eye
Office system incorporates a “sketch mode” that
allows you to draw or highlight the animation, right
on the screen. This enables you to personalize your
presentations and to save valuable chair-time. In a
discussion of presbyopia, for example, showing how
the lens hardens or loses its flexibility over time takes
only a few seconds. You can begin by showing the Fig. 5: The aging lens resulting in driving glare
60 Multifocal IOLs
screen in sketch mode also adds a “wow” factor to
the presentation that helps you to make the strongest
impression.
When chair-side education by the physician is not
practical because of time constraints, 3-D Eye Office
also allows animation to be played in full using
“video mode.” This option is ideal for practices in
which physicians or staff must move rapidly between
multiple examination lanes.
THE IMPORTANCE OF MANAGING
EXPECTATIONS
When the patient sits with a surgical counselor in
the consultation lane, animation is a very useful tool
to explain all the details of an operation, including
the benefits and risks associated with the procedure.
The 3D-Eye Office system makes it easy for patients
to understand what they can expect from surgery
and their IOL options. For example, you can simulate
the effects of a multifocal IOL by showing animation
of a patient’s point of view with both distance and
near objects in focus at the same time. You can segue
to a simulation of a car driving at night to illustrate
how postoperative glare or concentric halos can be
one of the initial effects of multifocal lenses. You
can also show how the brain compensates for this
glare, over time, by showing an animated segment
of the improvement in vision that comes with
neuroadaptation. Patients who need a more
thorough understanding of refractive errors such
as astigmatism can receive this information during
the consultation session. When showing the premium
lens options, it is important for you or your technician
to remind patients that spectacle independence is
possible but not guaranteed.
PATIENT ADMINISTRATION USING
SOFTWARE TECHNOLOGY
3-D animation-based patient education technology
is easy to integrate with computer software-based
patient administration and electronic medical record
systems. Our findings show that the most successful
refractive IOL practices present animation to their
patients using data administration3 systems already
in place throughout the practice. Practice manage-
ment software (PMS) and/or electronic medical
record (EMR) technology systems utilize computer
Fig. 6: The virtual office
terminals in strategic areas of the clinic to ensure
efficient data entry and information recall. In the
best PMS/EMR models, information efficiently
moves through the clinic along with the patient. This
process allows for instantaneous access to the
electronic health record throughout a patients’ visit.
These same PC terminals or supplemental terminals
can be used to educate patients at each step of their
visit—reception room, examination lane, and surgical
consultation area. Different animations can be
programmed into each area as appropriate for the
setting. The Figure 6 demonstrates office POV.
3D-Eye Home
According to David F. Chang, MD, “…it is…far more
efficient and effective to initiate presbyopia IOL
education in advance of (the patient’s) office visit.”4
With Eyemaginations’ latest technology, “3-D
Home,” patients can receive easily understandable
educational messages prior to their visit or after the
visit. This technology allows the doctor to provide
detailed information specific to the patient on many
topics, including cataracts, cataract surgery with
phacoemulsification, and presbyopia-correcting IOL
technology (Figs 7A to D).
3D-Eye Advisor
With the assistance of prominent ophthalmic thought
leaders, Eyemaginations is developing a system
designed specifically to educate patients about
presbyopia-correcting IOL technology. This
 Eyemaginations 61

A B

C D

Figs 7A to D: IOL correction possibilities: (A) Cataract phaco, (B) Cataract MF-IOL,
(C) Cataract general IOL, (D) Cataract ACOM IOL

presbyopia-correcting IOL counselor will serve a REFERENCES

wide variety of practice styles and priorities. With
customizable content, you will be able to choose the
technologies you want to present and how to balance
the educational function and promotional function
of the programming.
HOW TO LEARN MORE
Those who wish to learn more about Eyemagi-
nations’ products and services may contact Eye-
maginations directly at 877.321.5481 or visit their
Web site at www.eyemaginations.com.
1. Hermann M. 3-Dimensional computer animation—a new
medium for supporting patient education before surgery.
Chirurgica 2002;73:500-507.
2. Binder S, Glittenberg C. Computer simulations in
ophthalmic training. The College of Optometrists.
Ophthal Physiol Opt 2006;26:40-49.
3. According to Wikipedia, “data administration” is the
administration of the organization of data, usually as
stored in databases under some database management
system or alternative systems such as electronic
spreadsheets.
4. Screening and Counseling Refractive IOL Patients.

8
The Current Status of
Multifocal IOLs
Multifocal IOLs have been under development,
clinical study and implantation for more than 20 years
now, yet it is only now, in late 2007, that we now start
to see a burgeoning interest in the implantation of
these devices. There are a number of reasons that this
is the case. First, improved technology of the second
and third generation multifocal IOLs, compared to
first generation devices, means greater patient
satisfaction. Second, cataract patients have greater
expectations about their vision following lens
removal. Third, there is greater awareness that there
are limitations with laser vision correction when it
comes to higher ranges of refractive error, meaning
more surgeons are turning to IOLs.
Recent evidence presented at international
ophthalmology meetings certainly supports the
growing interest in refractive IOLs. Results of a survey
of members of the International Society of Refractive
Surgery presented at the 2007 meeting of the
American Academy of Ophthalmology showed that
there was an increase in the use of phakic IOLs.
Richard J. Duffey, MD, reported that 41 percent of
those responding preferred phakic IOLs for myopic
correction, while he noted that LASIK had dropped
to 33 percent.1 Data presented by Steven J. Dell, MD,
at the OSN New York Symposium showed that
premium lens-based refractive surgery could become
the second leading elective procedure in the United
States.2 The data reported that between 10 and 30
percent of Medicare-eligible (65 and over) patients
were opting for a premium IOL, while closer to 50
percent of those under 65 were selecting these lenses
for vision correction.
The Current Status of Multifocal IOLs 65
H Burkhard Dick
THE CURRENT OFFERING OF
MULTIFOCAL IOLs
At this writing, there is a wide variation in available
multifocal IOLs between the United States and the
rest of the world, particularly Europe. At present,
there are two multifocal IOLs approved by the U.S.
FDA—the AcrySof ReSTOR (Alcon Laboratories, Ft.
Worth, TX) and the ReZoom multifocal IOL
(Advanced Medical Optics, Santa Ana, CA). In
Europe, the product offering is much wider with
additional offerings from AMO (the Tecnis ZM900
IOL), as well as Acri.Tec (now a part of Carl Zeiss
Meditec), Morcher and Rayner (Table 1). The reality
is that the route to market in Europe is less
complicated than what is encountered in Europe with
medical device manufacturers being required to
demonstrate conformity to the appropriate esta-
blished regulations set up by the European Union
for CE marking. Although quite rigorous, the path to
regulatory approval in Europe is shorter, which
means quicker access to new products.
As of this writing, there are more than
30 different types of refractive IOLs on the market
in Europe in the categories of multifocal, toric,
refractive and accommodative (Table 1).
MULTIFOCAL IOLS
Generally speaking, available multifocal IOLs can be
categorized into two types: refractive and diffractive.
However, there also is now available one multifocal
that is described as a refractive-diffractive IOL and
another that is a combination of a multifocal and
accommodative IOL.
 66
Table 1: Currently available multifocal IOLs
Company Model Material Design Indication Features/Benefits Available Powers

AcriTec Acri.LISA 356D Hydrophobic One piece, c-loop, 6 mm optic Multifocal IOL Refractive-Diffractive surface 0 to +44 D
acrylic w/overall diameter of 11.5 mm w/optimized aspheric optic.
Asymmetrical light distribution.
Multifocal IOLs

Pupil independent. Good visual

acuity at near, intermediate and
distance. Patient satisfaction of
more than 96%

Acri.LISA 366D Hydrophobic Plate, 6 mm optic w/overall Multifocal IOL As described above 0 to +32 D
acrylic diameter of 11 mm

Acri.LISA 536D Hydrophobic 3-piece c-loop, 6 mm optic Multifocal IOL As described above 0 to +44 D
acrylic w/overall diameter of 12.5 mm

Acri.Twin Hydrophobic Plate, 6mm optic w/overall Multifocal IOL Twin system contains distance 0 to +44 D
447D/443D acrylic diameter of 11 mm dominant and near dominant IOLs
to improve binocular visual acuity.
Asymmetrical distribution of light.
Pupil independent. Diffractive
surface profile

Acri.Twin Hydrophobic 3-piece c-loop, 6 mm optic Multifocal IOL As described above 0 to +44 D
527D/523D acrylic w/overall diameter of 13 mm

Acri.Twin Hydrophobic 3-piece c-loop, 6 mm optic Multifocal IOL As described above 0 to +44 D
737D/733D acrylic w/overall diameter of 12.5 mm +10 to +30 D

Alcon Labs ReStor SN60D3 Hydrophilic 1-piece modified L Multifocal IOL Diffractive optic w/12 zones +10 to +30 D
acrylic w/blue and UV blocking for a total add of 4 D.

ReStor SA60Ds Hydrophilic 1-piece modified L Multifocal IOL As described above

acrylic w/UV blocking

Advanced
Medical Optics
Contd...
Contd...

Company Model Material Design Indication Features/Benefits Available Powers

(AMO) Tecnis ZM900 Silicone 3-piece c-loop, 6 mm optic Multifocal IOL Diffractive posterior surface and +5 to +34 D
w/overall diameter of 12 mm prolate anterior surface. Light is
split evenly between near and
distance vision that is pupil
independent. Prolate design
compensates for spherical
aberrations

ReZoom Hydrophobic 3-piece c-loop, 6 mm optic Multifocal IOL Refractive with a combination of +5 to +30 D
acrylic w/overall diameter of 12 mm 5 near and distance zones and
transitions to provide intermediate
vision. Designed to provide full range
of vision with 100% light transmission

Carl Zeiss MF4 Hydrophilic 1-piece, tripod design, Multifocal IOL 4-zone optic with total near add of +15 to +26 D
Meditec acrylic 6 mm optic +4 D with “autofocus”

Morcher BioComFold 43S Hydrophilic 1-piece, ring-haptic IOL, Accommodative, Hybrid accommodative IOL with a 10 to 30 D
acrylic 5.8 mm optic w/overall Multifocal IOL refractive multifocal optic
diameter of 10.20 mm

Rayner M-Flex 630F Hydrophilic 1-piece, 6.25 mm optic Multifocal IOL 4 or 5 zone aspheric lens +14 to +25 D and
acrylic w/overall diameter of 12.5 mm (depending on dioptic power) +18.5 to +23.5 D
with distance dominant focus
and a total add of +3 D.
Anatomically correct for highly
myopic eyes
The Current Status of Multifocal IOLs 67
68 Multifocal IOLs

REFRACTIVE MULTIFOCAL IOLs

ReZoom Multifocal IOL (Advanced Medical Optics,
Santa Ana, CA). This IOL is a 3-piece hydrophobic
acrylic IOL with five refractive zones (Fig. 1): (Moving
from the outside zone to the center) A low light/
distance dominant zone; a near zone; a distance zone;
a second near zone and a bright light/distance
dominant zone in the center. Transition between the
zones provides intermediate distance vision. The
manufacturer states that its design called “Balance
View Optics”, allows for 100% light transmission over
all five optical zones (Fig. 2). The ReZoom has a
rounded anterior and a sharp posterior edge design
(OptiEdge).
The ReZoom is an evolution of the first multifocal Fig. 1: Overview of the ReZoom multifocal IOL photographed
IOL to become commercially available in the U.S., the at high magnification using scanning electron microscopy
Array. However, the manufacturer has changed the (SEM)
near and distance zone areas in order to reduce visual
effects such as halos. The addition of the intermediate
transition zones is also said to improve the
performance of the lens, even when near and distance
powers are out of focus.3

ReZoom Clinical Results

In a study we conducted on the ReZoom (n = 24), it
was compared to the Array IOL (n = 18) in terms of
visual acuity, unwanted visual symptoms and
defocus acuity curves.
The mean binocular distance uncorrected visual
acuity (UCVA) was 20/20 while the mean binocular
distance best-corrected visual acuity (BCVA) was 20/
17. For distance-corrected near visual acuity, 83.3
percent of the ReZoom patients were 20/40 or better.
The results showed similar defocus acuity curves
for near and intermediate vision with both Fig. 2: Intraoperative photograph of the zonal distribution
multifocals. A greater number of ReZoom patients in the ReZoom optic
reported spectacle independence with 67 percent of randomized to receive either the ReZoom or the
patients never needing glasses, while 100 percent Array after cataract surgery. At six months
reported that they did not need glasses for distance, postoperative, patient satisfaction was similar
and 95 percent had no need for glasses at intermediate between the two groups, as was distance vision. The
distances. Patients in the ReZoom group also reported difference between the outcomes becomes apparent
fewer unwanted visual side effects, such as halo or when you look at the percent of patients who
glare. required spectacle correction following surgery—
A study presented at the 2005 meeting of the 80 percent of the ReZoom patients were spectacle
American Society of Cataract and Refractive Surgery free compared to 60 percent of the Array patients.4
by Longhena, et al, reported on 30 patients who were (10 in Solomon and Donnenfeld article).
 The Current Status of Multifocal IOLs 69

M-Flex Multifocal IOL (Rayner, Hove, East

Sussex, UK). This refractive multifocal is relatively
new to the European market. The M-Flex is a
hydrophilic acrylic with a multi-zone aspheric optic
(Fig. 3). Depending on the IOL base power, there
are 4 or 5 zones. This IOL has a distant dominant
design with a +3 D near add. To the best of our
knowledge, no clinical data has been published on
this multifocal IOL.
MF4 Intraocular Lens (Carl Zeiss Meditec, Jena,
Germany). A one-piece, hydrophilic acrylic with a 4-
zone optic, the manufacturer describes the lens as an
“autofocus” multifocal. First developed and
introduced by IOLTech, little has been published in
the way of clinical results. Two studies have been
published to date on this lens, both in 2003, one in a
Fig. 3: Overview of the M-Flex multifocal IOL photographed
Spanish ophthalmology journal and the second in a at high magnification using SEM
German ophthalmic publication.

Clinical Results
The Spanish study compared the MF4 to an earlier
diffractive multifocal IOL developed by Pharmacia,
the 811E. In the study, 47 eyes were implanted with
the 811E IOL while 52 eyes were implanted with
the MF4 IOL. The study found that the diffractive
multifocal provided better BCVA for both distance
and near vision.5 The German study looked at the
results of the MF4 implanted bilaterally in 40 patients.
At 3 months postoperative, 92 percent of patients
had a UCVA of 20/40 or better, while 86 percent of
patients had an uncorrected near visual acuity of 20/
25 or better. Sixty-seven percent of the patients no
longer required glasses, while 27 percent reported that Fig. 4: Detail photograph of the apodized anterior optic of
they needed glasses “frequently.”6 the ReSTOR multifocal IOL using SEM

DIFFRACTIVE MULTIFOCAL IOLs
AcrySof ReSTOR (Alcon Laboratories, Ft. Worth,
TX). Based on one of the original multifocal IOL
designs (the 3M diffractive), this is a one-piece
hydrophobic acrylic that is capable of being injected
through a 2.8-mm incision. The manufacturer calls
the ReSTOR an apodized diffractive and it has 12
zones with a total near add of 4 D (Fig. 4). In late
2007, the company introduced an updated version
of the lens with the addition of an aspheric design.
In doing so, the company noted that there is a
growing acceptance for aspheric IOLs.
The optical design of the ReSTOR is such that it
creates an equal distribution of light between near
and far images in pupils up to 3.6 mm. Once the
pupil becomes larger than this, there is a shift of
light to the lens power with the theory being that
more light is required for near tasks compared to
distance tasks, such as driving at night.3
ReSTOR Clinical Results
The study conducted to get FDA approval of the
ReSTOR involved 820 patients with 760 available at
1 year for follow-up.7 Of these patients, 566 received
70 Multifocal IOLs

a ReSTOR multifocal, while 194 were implanted with

a monocular AcrySof IOL.
Combined distance and near visual acuity showed
that 84 percent of patients were 20/25 and J2 or better
uncorrected. In the monofocal group, 23 percent
achieved the same result. Approximately 25 percent
of the multifocal group experienced glare or halos
compared to between 3 and 9 percent in the
monofocal group.
A prospective study published in 2007 looked at
distance, intermediate and near vision in patients
implanted bilaterally with one of two models of the
ReSTOR – model SA60D3, n = 325 or model SN60DS
(AcrySof Natural ReSTOR), n = 335.8 At six months
postoperative, the binocular distance BCVA for the
AcrySof ReSTOR group was 0.034 logMAR ± 0.004 Fig. 5: Detail photograph of the posterior surface of the Tecnis
(SD) and for the AcrySof Natural ReSTOR group was multifocal optic showing diffractive rings over the entire 6 mm
0.019 logMAR ±0.020, which was approximately 20/ surface using SEM
20. Binocular near BCVA was 0.011 ± 0.012 for the
ReSTOR group and 0.035 ± 0.013 for the Natural
ReSTOR group. The intermediate vision worsened in
both groups as a function of the distance of the test
(p < 0.01). The study found that photopic contrast
sensitivity was within normal ranges for both groups,
while the mesopic contrast sensitivity was compa-
rable to a monofocal IOL and lower at higher spatial
frequencies than what was seen under photopic
conditions.
A German and Swiss study comparing the
ReSTOR to the Array multifocal found that patients
reported that they had similar distance visual acuities
for both eyes.9 The study involved implantation of
Fig. 6: Tecnis multifocal IOL at the slit-lamp
the ReSTOR in 18 post-cataract patients, with the
Array implanted in the fellow eyes. The ReSTOR eyes
had better uncorrected and best-corrected visual design leads to better focusing and shaper vision.
acuity for near and distance compared to the Array The haptics consist of clear PVDF (polyvinyliden-
eyes (p = 0.002 and p = 0.003, respectively). fluoride) with a C-design, with middle of the sharp
Intermediate vision was slightly better in the Array optic edge.
eyes (p = 0.058). A number of clinical studies have recently been
Tecnis ZM900 (Advanced Medical Optics, Santa published on the performance of the Tecnis multifocal
Ana, CA). The Tecnis ZM900 is available in either a IOL including a German study that looked at
hydrophobic acrylic model or in a silicone model functional visual outcomes between it and the Array
outside of the U.S, although FDA approval is expected multifocal. In this prospective study of 50 cataract
in 2008. The diffractive design on the posterior surface patients, 25 patients were bilaterally implanted with
creates two focal points that are 4 D apart (Figs 5 the Tecnis multifocal and 25 patients were bilaterally
and 6). The anterior surface has a modified prolate implanted with the Array.10 Patients were assessed
design that is intended to compensate for spherical at 30 to 60 days postoperative and then again at
aberration (Fig. 7). The manufacturer claims that this between 120 and 180 days for BCVA and UCVA at

Fig. 7: Anterior aspheric optic surface of the Tecnis
multifocal IOL (SEM)
near and distance, as well as contrast sensitivity.
The study found that the Tecnis multifocal IOLs
performed better in UCVA near vision, distance
BCVA and the mesopic contrast sensitivity at high
spatial frequencies. Patients also reported less need
for spectacles in the Tecnis multifocal group, resulting
in greater patient satisfaction.
A comparison of the Tecnis multifocal with the
ReSTOR IOL involved 28 patients who were
randomized to receive one of the IOLs following
cataract surgery.11 The results found no statistically
significant difference between the two groups for high
and low contrast UCVA and BCVA distance vision.
The distance corrected near visual acuity was 1.86
±1.66 in the Tecnis group and 1.93 ±1.12 in the
ReSTOR group. There were significantly lower levels
of total aberrations, including spherical and coma,
in the Tecnis group, leading the researchers to
conclude that the Tecnis provided better quality of
vision.
A study looking at reading speed and ability in
patients implanted with three different types of
multifocal IOLs found that patients with the Tecnis
multifocal had the best reading acuity and reading
speed compared to the Array multifocal and the
AcrySof ReSTOR.12
Finally, a study due to be published in 2008 looks
at outcomes with the Tecnis multifocal in patients
undergoing refractive lens exchange. 13 In the
prospective study of 59 eyes of 30 patients, 90% of
patients achieved a monocular distance UCVA of 20/
The Current Status of Multifocal IOLs 71
30 or better at six months, while 90% achieved J1 or
better uncorrected. Patient satisfaction in this series
was high with 96.4% indication that they were very
satisfied and would select the same lens again.
Acri.Twin Multifocal (Acri.Tec, Henningsdorf,
Germany). These diffractive multifocals are actually
a set of two IOLs. One IOL is a distant-dominant
multifocal (70% distance and 30% near) and the other
is a near dominant multifocal (30% distance and 70%
near). The idea is to provide more effective
pseudoaccommodation, according to the manu-
facturer. The IOLs have a total near add of +4 D.
There have been a number of studies published
involving implantation of the Acri.Twin lenses. A
small German study compared results with the
Acri.Twin to eyes implanted with a standard
monofocal (PhacoFlex SI-40, AMO) or the Array
multifocal.14 The authors found that the Acri.Twin
lenses provided better distance and near vision, as
well as better contrast sensitivity.
An Austrian study that compared depth of focus
results among different multifocal IOLs found that
the Acri.Twin lenses had better near and distance
visual acuity results compared to the other two types
of multifocals used in the study (Array and 811E).15
Patients with the diffractive multifocals also had
better reading results. The study concluded that
asymmetric-weighted IOLs, such as the Acri.Twin
lenses provide better binocular depth of field.
Another study to compare the Acri.Twin
multifocals with the Array multifocal yielded similar
results.16 In this study, researchers looked at the 6-
month visual outcomes of 16 patients implanted
bilaterally with the Acri.Twin IOLs and 14 patients
who had undergone bilateral Array implantation. The
Acri.Twin patients had better visual outcomes,
although the study found that contrast sensitivity in
both multifocal groups was less than published rates
for an aspheric monofocal IOL.
Combination Refractive-Diffractive
Multifocal IOLs
Acri.LISA 366D, 356D and 536D (Acri.Tec,
Henningsdorf, Germany). These hydrophobic acrylic
multifocal IOLs are a hybrid design with both
refractive and diffractive components. LISA actually
stands for: L-light intensity distribution of 65% far
72 Multifocal IOLs

(refractive) and 35% near (diffractive); I-indepen-

dent from pupil size; S-smooth refractive/diffractive
surface profile, and; A-optimized aspheric surface.
There are three available designs: a one-piece c-loop
(356D); a plate-style (366D), and; a three-piece, c-loop
(536D). All the lenses have a total near add of
+3.75 D.
In one study on the Acri.LISA, the IOL was
implanted bilaterally in 20 patients after cataract
surgery. 17 At 6 weeks postoperative, the mean
binocular UCVA and BCVA (logMAR) were -0.02
±0.10 and -0.07 ±0.09, respectively for distance. For
near, the UCVA was 0.09 ±0.16. The visual acuity was
statistically superior for binocular vision compared
to the monocular rests.
A Spanish study looked at the results of 81 patients Fig. 8: BioComFold 43S: a hybrid of accommodative and
who had bilateral implantation of the Acri.LISA lens. multifocal IOL technology (SEM)
The results showed improved vision at all distances,
as well as improved binocular contrast sensitivity at
all spatial frequencies under photopic and mesopic between 450 and 600 microns in thickness and uses
conditions.18 a diffractive optic principle known as multi-order
BioComFold 43E and 43S (Morcher, Stuttgart, diffraction. 21 This involves bringing multiple
Germany). This is a single-piece, hydrophilic acrylic wavelengths to a common focus, forming sharp, clear
with a disc-like shape and a peripheral bulging, images in white light. This apparently allows the
discontinuous ring. This ring is connected to the optic IOL to be a constant thickness no matter what the
with an intermediate, forward-angled perforated ring
refractive power, as well as eliminating chromatic
section. The optic is positioned in front of the ring
aberrations.
that results in a forward shift when the ciliary muscle
contracts on the haptic. The 43S operates on the same
principle but has a refractive multifocal optic and a COMBINING DIFFERENT TYPES OF
10° anulation (Fig. 8).19 MULTIFOCAL IOLs
As interest in multifocal IOLs has grown in recent
ANTERIOR CHAMBER MULTIFOCAL IOL years, surgeons have looked for ways to optimize
the results in order to help patients achieve spectacle
Vision membrane: This is a new entry into the multi- free vision. This is, in part, due to the limitations of
focal arena and has only recently begun clinical each multifocal IOL design. While refractive designs
studies. A report presented by California tend to be better at providing better distance and
ophthalmologist, Lee Nordan, MD, at the 2007 intermediate vision, the diffractive designs provide
annual meeting of the American Academy of better near and distance visual results. By combining
Ophthalmology in New Orleans, described two cases the two design types, or in the case of the Acri.Twin,
where the Vision Membrane IOL was implanted in a near-dominant IOL and a distance dominant IOL,
pseudophakic presbyopes.20 will help to compensate for these limitations.
The first study to be published on combining
The Vision Membrane IOL is a thin-vaulted different types of multifocal IOLs involved looking
membrane made of silicone and is capable of at results of patients who were implanted bilaterally
implantation through a 2.6 mm incision. It averages with the accommodating Crystalens (Eyeonics, Aliso
 The Current Status of Multifocal IOLs 73

Viejo, CA), AcrySof ReSTOR or ReZoom or received and works at a computer, than the option of
a combination of the Crystalens and ReSTOR or the combining different types of multifocal IOLs makes
Crystalens and ReZoom.22 The results showed that sense in order to provide patients with the widest
the combination of the Crystalens and the ReSTOR range of vision without requiring spectacles.
was better for intermediate and near vision and that
any combination of the accommodating lens with a EVOLUTION OF USAGE OF MULTIFOCAL IOLs
multifocal resulted in fewer night glare symptoms.
It is quite clear that the use of multifocal IOLs remains
A study by Belgium surgeon Frank Goes that is
on an upward trajectory. As mentioned at the
currently in press looked at visual results in 40 eyes
beginning of this chapter, usage rates in the US are
of 20 patients implanted with a combination of the
on the rise. The same can be said for Europe. Helping
ReZoom multifocal in the dominant eye with the
to drive this growth is increased patient awareness
Tecnis multifocal in the non-dominant eye.23 The
about refractive IOLs and treatment options. Many
results showed that at two months postoperative, the
consumers now rely heavily on Internet research and
patients had good vision at all distances – near,
come well armed with information and questions
intermediate and far.
about the best treatment options. This is great news,
Other studies that have been presented at various
with a caveat: growing patient awareness means
meetings in recent years have also reported positive
greater expectations. Without proper education and
results when two different multifocal IOLs were
awareness about some of the drawbacks seen with
combined. A study presented at the 2003 annual
multifocal IOLs, this represents a great risk. Even
meeting of the American Society of Cataract and
though second and third generation multifocal IOLs
Refractive Surgeons, looked at a series of 30 cataract
carry much fewer visual disturbances than what was
patients implanted with a refractive multifocal (Array,
seen with the first generation models, there remain
Advanced Medical Optics, Santa Ana, CA) and a
issues with glare and halos. Plus, numerous studies
diffractive multifocal (811E CeeOn IOL, Pharmacia)
have shown that there is a measurable decline in
between 2000 and 2001. (Gunenc. Oral Presentation,
contrast sensitivity, although this is not as great when
American Society of Cataract and Refractive
an aspheric multifocal, such as the ReZoom, the
Surgeons, Annual Meeting, 2003, San Francisco, CA).
Tecnis and the new AcrySof ReSTOR aspheric are
In this study, 10 patients received the diffractive
used.
multifocal in 1 eye, 10 received the refractive
Careful patient selection and informed consent
multifocal in 1 eye and the remaining 10 underwent
remains of paramount importance before these IOLs
bilateral implantation with the refractive multifocal
are implanted.
in 1 eye and the diffractive multifocal in the other
Equally important is the need for patients to
eye. The results showed that 90% of the bilateral
understand that there is a limitation to how much
group was able to function without spectacles for
refractive error, particularly cylinder, these IOLs can
near and distance tasks, compared to 60% in the
correct. As such, some patients will continue to
unilateral groups.
require a refractive “touch-up” after multifocal IOL
At the 2006 ASCRS annual meeting, Frank Bucci,
implantation in order to provide the best possible
MD, reported on a series of 39 patients implanted with
outcome. The good news is that these so-called
a combination of ReZoom and ReSTOR compared to
Bioptics procedures have proved successful.
a series that were implanted with ReSTOR bilaterally
(n=55). This study found that combination group had
a mean intermediate vision of J2.39, compared to J3.81 CONCLUSIONS
in the ReSTOR group, although the near vision results Certainly there is a great deal of evidence that
were almost equal (1.06 for mix and match vs. 1.00 supports the increased usage of multifocal IOLs. The
for the ReSTOR group). (Oral presentation, ASCRS studies published on these second-generation
annual meeting, March 2006, San Francisco). multifocal IOLs are promising and patients should
Particularly when one is faced with a 50-something be encouraged to consider them, particularly if they
presbyope who still wants to have good driving vision are motivated to stop using spectacles or contact
74 Multifocal IOLs
lenses. Newer technology multifocals, such as the
Vision Membrane IOL, hold great promise in helping
us to deliver even better pseudoaccommodative
vision without some of the trade-offs some patients
currently experience.
REFERENCES
1. LASIK seeing decline among refractive surgeons. OSN
Supersite (www.osnsupersite.com). 2007.
2. Baby boomers and Generation Y expected to boost
refractive numbers. OSN Supersite (www.osnsu-
persite.com). 2007.
3. Solomon R, Donnenfeld ED. Refractive intraocular
lenses: Multifocal and Phakic IOLs. International
Ophthalmology Clinics 2006;46(3):123-43.
4. Longhena P, Gaiba G, Brandi L., et al. Array MIOL vs a
multifocal IOL with new profile and material: ReZoom.
American Society of Cataract and Refractive Surgeons,
annual meeting, San Francisco. 2006.
5. Lieo Perez A, Alonso Munoz, Sanchis Gimeno JA, Marcos
Jorge MA, Rahhal MS. Comparative clinical study of
visual results between two different types of bifocal
intraocular lenses (Spanish). Archivos de la Sociedad de
Oftalmologica 2003;78:665-73.
6. Rau M, Bach C. Initial results obtained with multifocal
lens, MF-4 (German). Klin Montasbl Augenheilkd.
2003;220:24-28.
7. AcrySof ReSTORE. Physician labeling, rev 1. Fort Worth,
TX, Alcon Laboratories.
8. Alfonso JF, Fernandez-Vega L, Baamonder MB, Montes-
Mico R. Prospective evaluation of apodized diffractive
intraocular lenses. J Cataract Refract Surg 2007;33:1235-
43.
9. Renieri G, Kurz S, Schneider A, Eisenmann D. ReSTOR
diffractive versus Array 2 zonal-progression multifocal
intraocular lens: a contralateral comparison. Eur J
Ophthalmol 2007;17:720-26.
10. Mester U, Hunold W, Wesendahl T, Kaymak H.
Functional outcomes after implantation of Tecnis ZM900
and Array SA40 multifocal intraocular lenses. J Cataract
Refract Surg 2007;33:1033-40.
11. Toto L, Falconio G, Vecchiarino L, Scorcia V, et al. Visual
performance and biocompatibility of 2 multifocal IOLs:
six month comparative study. J Cataract Refract Surg
2007;33:1419-25.
12. Huetz WW, Eckhardt HB, Rohrig B, Grolmus R. Reading
ability with 3 multifocal intraocular lens models. J Cataract
Refract Surg 2006;32:2015-21.
13. Goes F. Refractive lens exchange with diffractive
multifocal Tecnis ZM900 IOL. J Refract Surg. In press,
2007.
14. Jacobi FK, Kessler W, Held S. Optical performance of
multifocal intraocular lenses. Investigation of the Array
SA40N vs. Acri.Twin at the ‘physical eye’ according to
Reiner and Jacobi (German). Ophthalmologe. 2007;
104:236-42.
15. Schmidinger G, Geitzenauer W, Hahsie B, Klemen UM,
et al. Depth of focus in eyes with diffractive bifocal and
refractive multifocal intraocular lenses. J Cataract Refract
Surg 2006;32:1650-56.
16. Mester U, Dillinger P, Anterist N, Kaymak H. Functional
results with two multifocal intraocular lenses (MIOL):
Array SA40 versus Acri.Twin (German). Ophthalmologe.
2005;102:1051-56.
17. Kaymak H, Mester U. First results with a new aberration
correcting bifocal intraocular lens (German).
Ophthalmologie. 2007: Epub ahead of printing.
18. Alfonso JF, Fernandez-Vega L, Senaris A, Montes-Mico
R. Prospective study of the Acri.LISA bifocal intraocular
lens. J Cataract Refract Surg 2007;33:1930-35.
19. Auffarth G, Dick B. Multifocal intraocular lenses: A review
(German). Ophthalmologie 2001;98:127-37.
20. Surgeon reports first experience implanting AC
multifocal IOL in pseudophakic presbyopes. OSN
Supersite (www.osnsupersite.com). November 10, 2007.
21. Lane S, Morris M, Nordan L., Packer M, et al. Multifocal
intraocular lenses. Ophthalmol Clin N Am 2006;19:89-
105.
22. Pepose JS, Oazi MA, Davies J, Doan JF, et al. Visual
performance of patients with bilateral vs. combination
Crystalens, ReZoom and ReSTOR intraocular lens
implants. Am J Ophthalmol 2007;144:347-57.
23. Goes F. Visual results following implantation of refractive
and diffractive multifocal IOLs: A mix and match
approach. J Refract Surg In Press.
 9
Current Status of
Accommodative IOLs
If we look at the treatment of presbyopia, up until
the recent past, there have been a variety of sub-
optimal modalities. These include progressive lens
spectacles, bifocal contact lenses, monovision using
contact lenses, intraocular lenses (IOLs) or conductive
keratoplasty, as well as certain, questionable
techniques including scleral implants and multifocal
excimer laser corneal surgery.
If we also review the recent improvements in
phacoemulsification of cataracts,1-3 we see that we can
say that cataract and lens extraction has become
incredibly safe and efficacious. At the same time, with
the use of partial coherence interferometry for axial
length measurement, 4 we can conclude that pre-
operative measurements and calculations today allow
for excellent results and continue to improve. As a
result of improved outcomes with lower energy,
smaller incisions, and adjunctive astigmatic techni-
ques, the increased accuracy and safety in cataract
surgery has led to a natural evolution into refractive
surgery.
There are certain limitations to corneal refractive
surgery including high hyperopia, high myopia,
cataract, and questionably presbyopia. It is highly
likely that lens modalities will become the dominant
refractive surgical procedure in the not-too-distant
future. In addition, newer techniques, specifically for
addressing the removal of soft, clear lenses, has led
to minimally invasive, maximally safe refractive lens
exchange. 5 Finally, with the fact that spherical
aberration remains stable within the cornea with
increasing age, but changes in the crystalline lens with
I Howard Fine, Richard S Hoffman, Mark Packer
increasing age, we know that any refractive surgery
performed on the cornea, including the most
sophisticated, custom shaping is going to be degraded
by changing spherical aberration in the human lens.
IOLs FOR REFRACTIVE LENS EXCHANGE
The IOLs available for refractive lens exchange that
address presbyopia currently available in the United
States include three lenses: the ReZoom (Advanced
Medical Optics, Santa Ana, CA), the ReStor (Alcon
Laboratories, Fort Worth, TX), and the Crystalens
(eyeonics, Aliso Viejo, CA). Currently under develop-
ment or investigation are the Tecnis Multifocal IOL
(Advanced Medical Optics, Santa Ana, CA), which
has achieved excellent results in Europe, as well as
the Synchrony Dual-Optic Accommodative IOL
(Visiogen, Irvine, CA), the NuLens Accommodative
IOL (Herzliya, Israel), the Smart IOL (Medennium,
Irvine, CA), and certain new and innovative
technologies.
With the continuing evolution of IOLs to address
presbyopia, it seems highly likely that accommoda-
tive IOLs will supplant multifocal IOLs for several
reasons. While multifocal IOLs require no accommo-
dative effort, they do require central nervous system
adaptation, will almost always have halos or blur
circles, some loss of contrast sensitivity, and are a bad
choice in the presence of age-related macular
degeneration or corneal guttata. Accommodative
IOLs, on the other hand, more closely mimic patients’
experience as pre-presbyopes. All of the light comes
76 Multifocal IOLs

from the object of regard, there is no need for central
nervous system adaptation, no unwanted retinal
images, no loss of light energy, no loss of contrast
sensitivity, and continuous excellent vision at all
distances is possible. Accommodative IOLs do require
adequate amplitude of accommodation to avoid
reading fatigue, and in most cases, require adequate
capsule clarity and elasticity; however, they hold the
greatest promise for the ideal future IOL.
There are several ways to characterize accommo-
dative IOLs and I believe the best method for
characterization is by mechanism of action. There are
lenses that theoretically move within the eye and
change refractive power, dual-optic IOLs, deformable
optic IOLs, and certain newer, innovative technology
IOLs that will be discussed.
data from Tracey Technologies (Houston, TX)
indicating that it really is a deformable optic IOL.
Tracey Technologies iTrace data indicate that there
is a curvature change in the IOL with accommodative
effort, which they call accommodative arching, or
asymmetric tilting of the lens. Figures 2 and 3 are
Tracey Technologies iTrace images which
demonstrate the difference between phakic
accommodation in a 19 year-old college student, and
accommodation in a 62 year-old patient with a
Crystalens AT-45. In the Crystalens patient the
change takes place in a very small portion of the

LENSES THAT MOVE IN THE EYE

Currently, the only accommodative IOL available
in the U.S. today, which is also available in Europe,
is the eyeonics Crystalens (Aliso Viejo, CA). The
initial version, the AT-45, has been supplanted by
the AT-50, and there is a new model soon to be
introduced, which has an additional one diopter add
in the center of the optic (Fig. 1). The Crystalens
gives excellent distance vision, excellent
intermediate vision, and fair near vision. Although
the theoretical mechanism of action is anterior
movement of the optic with a redistribution of ciliary Fig. 2: Tracey Technologies iTrace image of
body mass on accommodative effort,6 there is new accommodative demand for a 19 year-old college student

Fig. 3: Tracey Technologies iTrace image of accommodative

Fig. 1: The eyeonics Crystalens, AT-45 and AT-50 demand for a 62 year-old AT-45 Crystalens patient

central pupil, which suggests that there is a
deformation of the lens, rather than a full movement
of the lens, that results in the accommodative
amplitude (Fig. 4). The new AT-50 has the advantage
of a 5.0 mm, compared to a 4.5 mm optic, and parallel
sides, which allow for movement within the capsular
bag, with accommodative effort. The current AT-50
is injectible through a 2.5 mm incision, which allows
for relative astigmatism neutrality, with the
implantation of this lens.
New data presented at the American Academy
of Ophthalmology Spotlight Session on Cataract by
Kerry Solomon, MD, concluded that the Crystalens
in one eye in conjunction with either the ReStor or
the ReZoom, gives a greatest degree of spectacle
independence of all combinations of presbyopia-
correcting IOLs binocularly.7 The three-year follow-
up data for results with this lens are similar to the
FDA data gathered during the core-clinical trial
(Fig. 5). In quality of life surveys, it appears that out
of 130 patients surveyed, 25.8 percent of the patients
never wear spectacles and 47.7 percent wear
spectacles almost none of the time, leading to a rela-
tive spectacle independence of about 73.5 percent,
which is comparable to the multifocal lens data
surveyed in the US.
In our own practice, we have found that the
Crystalens is an excellent choice for high myopes,
most of whom were 20/20 and J1 without correction,
Fig. 4: Image demonstrating difference in shape of the
eyeonics Crystalens upon accommodative effort
Current Status of Accommodative IOLs 77
Fig. 5: Three year follow-up data for the eyeonics Crystalens
is similar to the FDA data gathered during the clinical trial in
the US
postoperatively. We believe this may be related to
the fact that the optic is thinner in high myopes than
in emmetropes or hyperopes, resulting in a greater
facility for deformation. Because the lens arches
posteriorly in the lens capsule, it may stabilize the
vitreous face and may result in a lowered incidence
of retinal detachment in high myopes undergoing
cataract and refractive lens exchange surgery. We
also found it to be an excellent first choice for very
tall people, because so much of their near work is at
intermediate distances. Monocular optics allow its
use in patients with early AMD and corneal guttata.
It is also our first choice for monocular cataract
patients who don’t want the second eye operated
until necessary because its monofocal optics requires
no central nervous system adaption. We have a 10
percent enhancement rate in hyperopes, which we
believe this is due to the fact that the effective lens
position following surgery is not predictable.
DUAL-OPTIC ACCOMMODATIVE IOLS
We are investigators in the FDA-monitored study
of the Visiogen Synchrony Dual-Optic Accommo-
dating IOL (Irvine, CA) (Figs 6 and 7). This IOL is
similar to a natural lens in its three-dimensional
configuration, and mimics the natural lens function.
It is available in a pre-loaded injector that goes easily
through a 3.8 mm clear corneal incision. Over 500
implantations have been achieved world-wide with
78 Multifocal IOLs

Fig. 6: Front and side view of the Visiogen

Synchrony Dual-Optic Accommodative IOL Fig. 8: Two year follow-up data on 23 patients implanted with
the Visiogen Synchrony Dual-Optic Accommodative IOL
(Source: Ossma IL presented at Refractive Subspecialty day
AAO 2005, Chicago, 11)

Fig. 7: The Visiogen Synchrony Dual-Optic

Accommodative IOL

11 surgeons outside of the US and ten US surgeons,

and they show a best-corrected visual acuity of 20/ Fig. 9: Binocular uncorrected visual acuity, line-by-line
assessment, of 32 patients implanted with the Visiogen
40 or better in 100 percent of the patients, and
Synchrony Dual-Optic Accommodative IOL (Source: Alarcon
distance-corrected near visual acuity of 20/40 or R, Bohorquez V, Functional vision with synchrony dual optic
better in 96 percent of the patients. Defocus curves IOL, ESCRS 2006, London)
result in a 3.2 diopter amplitude of accommodation.
The two-year follow-up of 23 patients (Fig. 8), shows
excellent uncorrected distance and distance-
corrected near visions. Data presented at the 2006
meeting of the European Society of Cataract and
Refractive Surgery (ESCRS), indicate excellent
uncorrected distance, intermediate and near vision
(Fig. 9).
Ultrasound biomicroscopy documents that
accommodative effort results in a forward movement
of the anterior optic with a greater separation of the
two optics, resulting in a higher plus-powered lens
(Fig. 10). There is less anterior subcapsular opacifi- Fig. 10: High definition UBM image demonstrates the
cation in the area overlying the silicone optic than mechanism of action for the Visiogen Synchrony Dual-Optic
seen with other silicone optics and less posterior Accommodative IOL
 Current Status of Accommodative IOLs 79

capsule opacification than with other silicone optics

perhaps due to an as yet unelucidated mechanism that
is related to the complete separation of the anterior
and posterior leaves of the capsule. The mesopic
contrast sensitivity, with (Fig. 11) and without glare
(Fig. 12), is similar to the single-piece acrylic IOL.
Figure 13 demonstrates that the average reading
speed in patients implanted with the Synchrony is
similar to that obtained with both of the multifocal
Fig. 13: Average reading speeds in patients implanted with
IOLs. the Visiogen Synchrony Dual-Optic Accommodative IOL, the
ReZoom, and the ReStor
DEFORMABLE OPTIC IOLS
One of the most promising new technologies is that consists of a posterior piston that, on accommo-
of the NuLens Accommodating IOL, from Herzliya, dative effort, displaces material in the center of the
Israel (Fig. 14A). This involves a two-piece IOL that lens to add power (Fig. 14B). It sits on top of the

Fig. 11: Mesopic contrast sensitivity, without glare, of the

Visiogen Synchrony Dual-Optic Accommodative IOL
compared to a single-piece acrylic IOL (Source: Ossma IL
Fig. 14A: The NuLens Real Accommodating IOL
and Cols, quality of vision with synchrony dual optic IOL, (Herzliya, Israel)
ESCRS 2006, London)

Fig. 12: Mesopic contrast sensitivity, with glare, of the

Visiogen Synchrony Dual-Optic Accommodative IOL
compared to a single-piece acrylic IOL (Source: Ossma IL
and Cols, quality of vision with synchrony dual optic IOL, Fig. 14B: Schematic showing the mechanism of action for
ESCRS 2006, London) the NuLens Accommodating IOL
80 Multifocal IOLs

collapsed capsular bag. The manufacturers of this

lens believe that an accommodative IOL must have
at least eight diopters amplitude of accommodation:
one for adjustment of the far plane, three for near,
and then double that number to avoid accommo-
dative fatigue. Three month data from a clinical pilot
study show that ten patients implanted with the
NuLens achieved an average of ten diopters of
accommodation. It is possible that even larger
amounts of accommodation will be achievable,
depending on the refractive index of the silicone
material that constitutes a portion of the deformable
material that is anteriorly displaced upon
accommodative effort.
The Power Vision IOL (Power Vision, Santa
Fig. 15: Schematic showing the mechanism of action for the
Barbara, CA) incorporates a new, applied micro-
PowerVision IOL (Slide Courtesy of Samuel Market, MD)TM
fluidic technology in a single-piece IOL. On
accommodative stimulation, microfluidic pumps
reversibly alter the radius of curvature, affecting an
increase in overall power for near vision purposes
(Fig. 15).
The FlexiOptic IOL, by Quest Vision Technologies
(Tiburon, CA) now licensed by AMO, has a
mechanism of anterior movement by axial travel of
the optic, plus optic shape change. Depending on
the refractive index of the material used, it has an
accommodative amplitude of between 3.3 and 4.5
diopters of accommodation (Fig. 16).
An extremely promising technology is the
thermodynamic, adjustable accommodating IOL, the
SmartIOL, from Medennium (Irvine, CA). This is a
hydrophobic acrylic polymer with a refractive index
of 1.47 that has a soft transition temperature of 20°-
30°, centigrade. At temperatures below 20°,
centigrade, it is a rigid solid; above 30° it is a soft Fig. 16: The FlexiOptic IOL, by VisionQuest, has a mechanism
of anterior movement by axial travel of the optic, in addition to
gel. It has 90 percent light transmission and a UV optic shape change (Slide Courtesy of AMO and John
absorber. It is designed to completely fill the capsular Hunkeler, MD)
bag and be a stable gel at body temperature. Since it
fills the capsular bag, there can be no decentration, capsulotomy, if necessary. However, because it a
edge effects, or glare. It is convertible to a solid rod hydrophobic acrylic, posterior capsule opacification
a room temperature, where it can be implanted is unlikely because of the adhesion between the
through a small incision into the capsular bag. The hydrophobic acrylic and the capsule, and because it
great advantage of this IOL is that it can take also completely separates the anterior and posterior
advantage of a normal sized capsulorhexis in capsule leaves (Figs 17-20).
comparison to other injectible IOLs, which require
capsulorhexes around the size of 1.0 mm, and NEW INNOVATIVE TECHNOLOGIES
therefore entail great difficulty in extracting clear The Calhoun Light Adjustable IOL allows for an
lenses. It can allow for YAG laser posterior alteration in power following the implantation into
 Current Status of Accommodative IOLs 81

Fig. 17: The Medennium SmartIOL as a rigid rod and a soft gel lens

Fig. 18: Schematic demonstrating the SmartIOL changing from rigid rod, at room
temperature, to soft gel lens, at body temperature

Fig. 19: The Medennium SmartIOL in the capsule (left) Fig. 20: The Medennium SmartIOL implanted in a
versus a human cadaver eye (right) human cadaver eye
82 Multifocal IOLs

the human eye. It consists of a photosensitive,

adjustable IOL constructed of a silicone matrix with
imbedded silicone sub-units, called macomers.
Irradiation of a portion of the lens causes polymeri-
zation of the macomers and results in diffusion or
migration of non-polymerized macomers into the
irradiated region. Accumulation of macomers in the
irradiated region causes swelling in that area,
resulting in a central thickening for an increase in
plus-power, a peripheral thickening for an increase
in minus-power, or toric power alterations by
irradiating along the appropriate lens meridian. The
digital light delivery device for irradiation can also
Fig. 22: The LiquiLens, by Vision Solution Technologies,
be utilized to address corneal higher order aberrations
when positioned for distance vision
by changes in the lens that compensate for them (Fig.
21). Results in the early clinical trials of this lens have
documented its efficacy. If this technology can be
advanced to sequential adjustability and combined
with other technologies, it would dramatically
advance the state of refractive lens exchange.
The LiquiLens, by Vision Solution Technologies
(Rockville, MD), will provide emmetropia at distance
and an accommodative mechanism that allows the
lens to achieve more than three-fold magnification
for near. It is 100 percent gravity dependent. The
optic consists of a fluid chamber that has a high-
refractive index fluid sitting above a lower-refractive
index fluid. Looking forward, the low-refractive
Fig. 23: The LiquiLens, by Vision Solution Technologies,
index fluid fills the pupillary space (Fig. 22), and on when positioned for near vision
downward gaze, the high-refractive index fluid
flows into the pupillary space creating more plus
power (Fig. 23). Pixels can also be embedded in a parent IOL (Fig.
24). Applying an electrical charge to the pixels can
change the index of refraction to obtain up to four

Fig. 21: The digital light delivery device for the calhoun light Fig. 24: Schematic of pixelate optics being embedded in a
adjustable lens parent intraocular lens

diopters of accommodative amplitude. A recharge-
able battery, the size and configuration of a capsular
tension ring, can be implanted along with the IOL.
Some of the pixels can be dedicated to recognizing
contrast with a mechanism similar to an autofocus
on a digital camera, so that reading results in an
increase in plus power of up to four diopters.
Presbyopia-correcting IOLs have to be
biocompatible, give a full field of vision, be aberra-
tion free, give continuous acuity from distance to
near with an adequate amplitude of accommodation
to avoid accommodative fatigue, have an appro-
priate filter for any unwanted light rays, and will
either prevent PCO or allow for YAG laser posterior
capsulotomy. I believe only an accommodative IOL
can achieve those requirements.
REFERENCES
1. Fine IH, Packer M, Hoffman RS. Use of power modu-
lations in phacoemulsification: Choo-choo chop and flip
Current Status of Accommodative IOLs 83
phacoemulsification. J Cataract Refract Surg 2001;
27(2):188-97.
2. Fine IH, Packer M, Hoffman RS. New phacoemulsification
technologies. J Cataract Refract Surg 2002; 28(6):1054-60.
3. Fine IH, Packer M, Hoffman RS. Power modulations in
new technology: Improved outcomes. J Cataract Refract
Surg 2004;30(5):1014-9.
4. Packer M, Fine IH, Hoffman RS, Coffman PG, Brown
LK. Immersion A-scan compared to partial coherence
interferometry: outcome analysis. J Cataract Refract Surg
2002;28(2):239-42.
5. Fine IH, Hoffman RS, Packer M. Optimizing refractive
lens exchange with bimanual microincision phacoemulsi-
fication. J Cataract Refract Surg 2004;30(3):550-4.
6. Marchini G, Mora P, Pedrotti E, Manzotti F, Aldigeri R,
Gandolfi SA. Functional assessment of two different
accommodative intraocular lenses compared with multi-
focal intraocular lens. Ophthalmology 2007;114(11):2038-
43.
7. Solomon KD. Refractive lens exchange: Are we over-
emphasizing the risk? Presentation in Spotlight on Cata-
racts 2007: Current Controversies in Cataract Surgery,
annual meeting of the American Academy of Ophthal-
mology, New Orleans, 2007.
 10
Clinical Results with the New
Generation of Multifocal
Intraocular Lenses
Ulrich Mester, Hakan Kaymak

The use of multifocal intraocular lenses (MIOL) has Three models of the new MIOL generation gained
been very limited in the past due to several drawbacks widespread acceptance: The Acri.LISA (Acri.Tec,
and limitations.1 Surgical techniques were not as Henningsdorf, Germany), the AcrySof ReSTOR, and
refined and predictable as they are today, and the Tecnis ZM900. The characteristics of these 3
accurate biometry to achieve emmetropia was MIOLs are summarized in Table 1.
challenging. Moreover, independence from glasses We performed clinical studies with these
could not be achieved in all patients, particularly for 3 MIOLs, comparing the Tecnis lens with a first-
near vision. Many patients complained of photic generation MIOL, the Array lens. The Acri.LISA was
phenomena, 2,3 and driving was impaired due to compared to results gained with the first-generation
reduced contrast sensitivity under mesopic condi- MIOL from Acri.Tec, the Acri.Twin. Our results with
tions.4,5 the ReSTOR lens were gained with the conventional
A new generation of MIOLs has been developed
and has been investigated in clinical studies. Several Table 1: Characteristics of 3 multifocal intraocular
new optical concepts were incorporated in theses lenses
lenses.
With the application of a diffractive optic, the
visual performance became independent of the pupil
size, which was one major drawback of the previous
MIOL generation with refractive optics.
The introduction of an aspheric lens design
enhances contrast vision, which could be demons-
trated previously in clinical studies with monofocal
IOLs.6-8
Another new concept is unequal light distribution
for distance and near vision, based on the consi-
deration that most patients prioritize distance vision.
A further development aims to improve distance
vision by apodization of the central diffractive optic
of the IOL and the combination with a peripheral
monofocal zone due to the greater pupil diameter for
far distance, particularly under dim light conditions.
To reduce the complaints due to stray light, smooth
steps within the diffractive pattern were engineered.
 Clinical Results with the New Generation of Multifocal Intraocular Lenses 85

model. Actually, we investigated the newly deve-

loped aspheric ReSTOR.

ACRI.LISA
Twenty patients with bilateral implantation of the
Acri.LISA were examined 6 weeks after surgery of
the second eye; 15 of the 20 patients were re-examined
after 1 year.
Monocular and binocular visual acuity (VA)
(uncorrected and best corrected) at the 6-week control
are shown in Figure 1 and the results after 1 year in Fig. 1 Impact of binocularity on VA 6 weeks after surgery
Figure 2. Despite the dominance for far distance of with Acri.LISA (ETDRS-charts, CAT)
this MIOL, near VA was also very satisfying (uncor-
rected monocular 0.85, binocular 1.05 under photopic
conditions, 350 cd/m²) (Fig. 3).
The defocus curve demonstrates the drop of VA
at intermediate distance, but it does not exceed the
critical limit of 0.5 (Fig. 4).
Overall satisfaction was 8.3 using a scale from 0
to 10 after 1 year. The superiority of the Acri.LISA
compared to the first-generation MIOL from
Acri.Tec (Acri.Twin) becomes visible when
comparing the contrast sensitivity assessed with the
Functional Acuity Contrast Test (FACT) instrument
(Fig. 5).9,10 When asked about photopic phenomena
6 weeks after surgery, 16 out of the 20 patients Fig. 2: Impact of binocularity on distance VA 1 year after
surgery with Acri.LISA (ETDRS-charts)
reported moderate halos under dim light conditions,
but none were overly concerned by them.
were re-examined at the 6-month control. The mean
spherical equivalent at the last follow-up visit (120 to
TECNIS
180 days) was 0.1 ± 0.4 D (mean ± SD, Tecnis) and 0.2
Twenty-three patients with the Tecnis MIOL (46 ± 0.6 D (mean ± SD; Array). This difference was not
eyes) and 24 patients with the Array MIOL (48 eyes) statistically significant.

Fig. 3: Impact of binocularity on near VA 1 year after surgery with

Acri.LISA tested with CAT
86 Multifocal IOLs

Table 2: Distance uncorrected visual acuity and best-

corrected visual acuity at days 120 and 180 assessed
by ETDRS-charts (number of letters)
Tecnis Array
N = 23 N = 24
EDTRS- VA ETDRS- VA
Score score
Uncorrected 48.2 ± 4.2 0.71 49.4 ± 6.8 0.77
Best corrected 52.2 ± 6.3 0.87 52.9 ± 5.4 0.91
Fig. 4: Defocus curve (binocular) 1 year after surgery with patients with the Array MIOL reported not wearing
the Acri.LISA.
glasses. This difference was predominantly due to
the need for reading glasses in the Array group;
only 1 patient in the Tecnis MIOL group needed near
correction versus 12 patients (50%) in the Array

Fig. 6: Uncorrected near VA 6 months after surgery

measured with Contrast Acuity Test (C.A.T.) (40 cm)
Fig. 5: Contrast sensitivity measured with Functional Acuity
Contrast Test (FACT) under photopic conditions (results of
2 different studies)

Binocular uncorrected and best corrected distance

VA did not show a statistically significant difference
between the 2 groups at all follow-up visits (Table 2).
In contrast, uncorrected as well as distance-
corrected near vision revealed significantly superior
performance of the Tecnis MIOL compared to the
Array MIOL (P < 0.001) (Figs 6 and 7). At 40 cm
distance and under photopic conditions, the Tecnis
MIOL group performed also significantly better than
the Array MIOL group at 25% (P< 0.001) and 12.5%
(P < 0.001) contrast levels but not at far distance.
Data are summarized in Table 3.
The questionnaire survey at the last follow-up
visit revealed a major difference between the 2
groups in terms of spectacle independence: 82.6% Fig. 7: Distance corrected near VA 6 months after surgery
of patients with the Tecnis MIOL versus 33.3% of measured with Contrast Acuity Test (C.A.T.) (40 cm)
 Clinical Results with the New Generation of Multifocal Intraocular Lenses 87

Table 3: Contrast visual acuity assessed at days 120 and 65.00 1.54
distance corrected

VA (decimal)
uncorrected
180 with ETDRS-Charts (distance) and with CAT (near) 60.00 1.25

Reading letters (ETDRS-Charts)

(number of Letters)
55.00 1.00
Tecnis Array P-value
50.00 0.80
N = 23 N = 24
45.00 0.63
Near
40.00 0.50
25% contrast 41.7 ± 9.9 36.3 ± 6.3 P<0.05
12.5% contrast 35.8 ± 9.5 30.4 ± 7.5 P<0.05 35.00 0.40

30.00 0.32
Far
monocular binocular
25% contrast 45.4 ± 6.8 47.5 ± 5.6 n.s.
10% contrast 37.0 ± 8.9 38.9 ± 5.8 n.s.
Fig. 8: Impact of binocularity on VA 3 months after surgery
with AcrySof ReSTOR
Table 4: Spectacle dependence
Tecnis Array
70.00 1.00
Glasses Prescribed?

Reading letters (CAT-Charts)

60.00 0.63
No 19 (82.6%) 8 (33.3%)
Yes 4 (17.4%) 16 (66.7%) 50.00 0.40

Type of Glasses Prescribed

VA (decimal)
Distance 3 (75.0%) 4 (25.0%)
Near 1 (25.0%) 6 (37.5%)
Bifocals 0 6 (37.5%)

MIOL group (Table 4). The most frequent photic monocular binocular
phenomenon reported by our patients was halos,
Fig. 9: Impact of binocularity on uncorrected near VA 3
which were more often associated with the Array months after implantation of the AcrySof ReSTOR
MIOL. However, 9 out of 23 patients with the Tecnis
multifocal lens also reported halos but without
serious complaints after 6 months.11

ACRYSOF RESTOR
In a prospective study, 30 patients received the
AcrySof ReSTOR after bilateral phacoemulsification.
The postoperative spherical equivalent was 0.24 ±
0.4 D after 3 months. Mean binocular distance vision
was 1.0 uncorrected and 1.18 best corrected (Fig. 8),
uncorrected near VA was 0.93 (Fig. 9). Contrast visual
acuity was 0.83 (25%) and 0.6 (10%) under both
photopic and mesopic conditions (Fig. 10). Contrast
sensitivity measured with FACT was within the
Fig. 10: Contrast VA under photopic and mesopic conditions
normal range.
3 months after implantation of the AcrySof ReSTOR. There
The defocus curve showed a pseudoaccommo- was no loss of VA under mesopic conditions
dation range of 5.5 D with a bifocal profile (Fig. 11).
The intermediate vision was sufficient for daily life were satisfied with their vision at the intermediate
activities for most of the patients; 91.0 % of patients zone. The questionnaire survey revealed that 83.0%
88 Multifocal IOLs
Fig. 11: Impact of binocularity on defocus curve 3 months
after implantation of the AscrSof ReSTOR
of the patients were completely spectacle indepen-
dent. This finding is supported by other investi-
gations.12
As the light distribution of the ReSTOR MIOL
depends on pupil size, we looked for the relationship
between pupil size and visual performance. A larger
pupil correlated significantly with better uncorrected
distance VA and smaller pupils with better near and
intermediate VA (Fig. 12). (Results presented at the
ASCRS-meeting, San Diego, 2007). Only 1 patient
complained seriously of halos 3 months after surgery.
DISCUSSION
Our differing experiences with 3 models of the latest
generation of MIOLs stem from different study
designs. Therefore, we cannot use these studies as a
valid functional comparison of the MIOLs
mentioned. Nevertheless, the following conclusions
can be drawn:
VA for distance is good with all 3 MIOLs and
comparable to that of monofocal IOLs (at least under
photopic lighting conditions).
Near vision is also sufficient, even with the
Acri.LISA despite the unequal light distribution in
favour of the far distance.
Contrast vision is within the normal range.
There is a significant drop of VA at the inter-
mediate distance with all 3 MIOLs. This stems from
the bifocal optical design of all 3 MIOLs. Therefore,
we should speak of “bifocal” intraocular lenses
instead of “multifocal” lenses to avoid disappointing
patients who might otherwise imagine that their
intraocular lenses will perform like progressive-add
glasses. On the other hand, the drop of VA in the
Fig. 12: Correlation of pupil size with uncorrected monocular
VA at different distances with the AcrySof ReSTOR (Early
Treatment of Diabetic Retinopathy Study(ETDRS)-charts and
Contrast Acuity Test (CAT)) AcrySof ReSTOR
intermediate distance did not exceed 0.5, which was
sufficient for daily life activities for most patients.
More than 80.0% of patients gained complete
spectacle independence with all 3 MIOLs. This
represents enormous progress compared to the Array
lens in which only one-third of patients were free of
glasses.
Even with the new MIOL designs, photic
phenomena, particularly halos, has not been totally
eliminated. These effects seem to be inherent in
MIOLs as a result of creating multiple images with
simultaneous focus. Fortunately, most patients are
usually not disturbed by these optical effects and
report that they become less noticeable over time.13,14
All the results in our studies were achieved without
additional refinement of postoperative refraction
using photoablative procedures. Laser vision
correction would likely further improve the attainable
results.
Precise biometry is crucial. Therefore, we use 3
different formulas to get as close to emmetropia as
possible. We do not recommend MIOLs for patients
who are expected to have more than 1 D of post-
operative astigmatism and are not willing to undergo
a second laser procedure for refinement. Toric MIOLs
may better address the problem of astigmatism in
the future.
A second crucial step is patient selection. Studies
to determine how to best identify suitable MIOL
patients are underway.
The authors have no financial interest in the
products mentioned in this article.
 Clinical Results with the New Generation of Multifocal Intraocular Lenses
REFERENCES
1. Leaming DV. Practice styles and preferences of ASCRS
members—2002 survey. J Cataract Refract Surg 2003;
29:1412-20.
2. Dick HB, Tehrani M, Brauweiler P, et al. Complications
with foldable intraocular lenses with subsequent
explantation in 1998 and 1999: result of a questionnaire
evaluation. Ophthalmologe 2002;99:438-44.
3. Mamalis N, Davis B, Nilson CD, et al. Complications of
foldable intraocular lenses requiring explantation or
secondary intervention— 2003 survey update. J Cataract
Refract Surg 2004;30:2209-18.
4. Auffarth G, Hunold W, Breitenbach S, et al. Contrast and
glare sensitivity in patient with multifocal IOLs: results
two years after lens implantation. Klin Monatsbl
Augenheilkd 1993;203:336-40.
5. Steinert R, Aker B, Trentacost D, et al. A prospective
comparative study of the AMO Array zonal progressive
multifocal silicone intraocular lens and a monofocal
intraocular lens. Ophthalmology 1999;106:1243-55.
6. Bellucci R, Scialdone A, Buralto L, et al. Visual acuity and
contrast sensitivity comparison between Tecnis and
AcrySof SA60AT intraocular lenses: A multicenter
randomized study. J Cataract Refract Surg 2005;31:712-
7.
7. Kershner RM. Retinal image contrast and functional visual
performance with aspheric, silicone, and acrylic
89
intraocular lenses: prospective evaluation. J Cataract
Refract Surg 2003;29:1684-94.
8. Mester U, Dillinger P, Anterist N. Impact of a modified
optic design on visual function: clinical comparative
study. J Cataract Refract Surg 2003;29:652-60.
9. Mester U, Dillinger P, Anterist N, Kaymak H. Functional
results with two multifocal intraocular lenses (MIOL).
Array SA40 versus Acri.Twin. Ophthalmologe. 2005;102:
1051-6.
10. Kaymak H, Mester U. Erste Ergebnisse mit einer neuen
aberrationskorrigierenden Bifokallinse (Acri.LISA),
Ophthalmologe. In press.
11. Mester U, Hunold W, Wesendahl T, Kaymak H. Func-
tional outcomes after implantation of Tecnis ZM900 and
Array SA40 multifocal intraocular lenses. J Cataract
Refract Surg 2007;33:1033-40.
12. Kohnen T, Allen D, Boureau C, et al. European multi-
center study of the AcrySof ReSTOR apodized diffractive
intraocular lens. Ophthalmology 2006;113:578-84.
13. Dick HB, Krummenauer F, Schwenn O, et al. Objective
and subjective evaluation of photic phenomena after
monofocal and multifocal intraocular lens implantation.
Ophthalmology 1999;106:1878-86.
14. Pieh S, Lackner B, Hanselmayer G, et al. Halo size under
distance and near conditions in refractive multifocal
intraocular lenses. Br J Ophthalmol 2001;85:816-21.
 11
IOL Calculation for
Multifocal IOLs
Wolfgang Haigis

INTRODUCTION contact ultrasound, the usage of which is conti-

nuously decreasing.3 Therefore, contact ultrasound
Generally, modern intraocular lenses (IOL) like
should not be used for multifocal IOLs; PCI biometry
aspheric lenses and lenses based on new technologies
is the method of choice in these cases.
(NTIOL) unfold their full potential only when all
Furthermore, as was already mentioned, the
error contributions are minimized and the intended
usage of correct and up-to-date lens constants is
refraction is reached right on the spot. This holds
decisive for good refractive results. It is important
especially for multifocal IOLS (MIOLs) for which the
to know the numerical influence of these constants
achieved postoperative refraction has to be very close
on the refractive results after MIOL implantation.
to the targeted emmetropia. Otherwise, the inherent
Of special interest is the question whether different
disadvantages of simultaneous imaging (e.g. contrast
surgeons at different ophthalmic centers all using
reduction) quickly outweigh the intended indepen-
the same measurement setup could apply the same
dency of spectacles and leave the patient with a
constants’ set or whether it is necessary for them to
refractive solution second best to classical monofocal
perform individual personalizations of their
IOLs. Apart from the surgery itself, the quality of
constants.
IOL calculation is a very important issue. It depends
The following study addresses these problems
on the selection of formula to calculate the lens
on the basis of results obtained by members of the
power needed for emmetropia, the quality of
User Group for Laser Interference Biometry (ULIB)4 with
measured patient data and – last not least – the
the Zeiss IOLMaster for the Alcon ReSTOR multifocal
quality of the lens constants which actually is
lens.
fundamental for IOL outcomes.
With properly optimized constants, all IOL power MATERIAL AND METHODS
formulas should produce comparable results for
Patient Data
normal eyes and differences will only show up at
the extremes, i.e. for short and long eyes1,2 (see also Data sets with pre- and postoperative results for
Figs1 and 2). patients having received an Alcon ReSTOR MIOL
Minimizing errors is equivalent to using the best were analyzed retrospectively. The data were sent
available techniques. This does not only hold for to the author within the framework of the ULIB
the surgical methods applied, but also for the project to optimize IOL constants for optical
measurement techniques, especially for biometry and biometry4 by five surgeons from South America and
keratometry. It is commonly accepted that optical one surgeon from Australia either directly or via
biometry and immersion ultrasound are superior to Dr. Warren Hill.5 A total of 340 patient datasets were
94 Multifocal IOLs

Fig.1: Axial length dependance of the arithmetic refraction prediction error (ARE) for all datasets,
calculated with the SRK II formula with the ULIB constants of Table 1.

Fig. 2: Axial length dependance of the arithmetic refraction prediction error (ARE) for all datasets,
calculated with the Haigis formula formula with the ULIB constants of Table 1
Within the ULIB project, the constants for all IOL
sent altogether (center #1: n = 35, #2: n = 38, #3: n = formulas in the IOLMaster had been optimized and
38, #4 : n = 18, #6 : n = 188, #5: n = 23). Each dataset published on the ULIB constants’ webpage.6 For the
contained preoperative biometry (axial length, optimization, custom-made computer programs were
anterior chamber depth) and keratometry (corneal applied performing an iterative mathematical process
radii) results obtained with the Zeiss IOLMaster, the for each IOL power formula by which the respective
spherical equivalent of the stable manifest lens constant is incrementally altered until the mean
postoperative refraction at BCDVA and the power arithmetic refraction prediction error ME (= achieved
of the ReSTOR MIOL implanted. —alculated refraction) is zero.

CALCULATIONS
For the purpose of this study, optimization was
carried out for each center individually and again
for all datasets together for the formulas of Haigis7
and Holladay.8 Calculations were performed for 2
scenarios:
1. For all centers the ULIB constants were used, i.e.
the constants derived from all n = 340 datasets.
Since n was large enough, all three constants (a0,
a1, a2) of the Haigis formula were optimized and
applied in the subsequent calculations.
2. For each center the respective individually
customized lens constants were used. Since in each
case ‘n’ was not large enough for triple
optimization, only the lens constant a0 in the
Haigis formula was optimized and subsequently
applied. The constants a1(= 0.4) and a2 (= 0.1)
were kept at their respective default values.
For each scenario, center and formula, the mean
arithmetic (ARE) and the mean absolute (ABE)
prediction errors (achieved—calculated refraction)
were calculated. In addition, since absolute errors
usually do not follow a normal distribution, the
medians of the absolute prediction errors were
determined.
Statistical evaluation was done with MS Excel
2000 (Microsoft Corp.) and SigmaStat for Windows
version 3.5 (Systat Software Inc.).
Table 1: Optimized IOL constants (‘ULIB constants’) of the AcrySof ReSTOR lens for different IOL power formulas,
based on n = 339 patient data sets from the ULIB constants page4 and statistical data [mean, standard deviation (sd)
and median] for the arithmetic (ARE) and absolute (ABE) refraction prediction errors (achieved—calculated refraction)
obtained with these constants for all datasets
Formula IOL constants
SRK/T A = 118.45
SRK II A = 118.65
Holladay-1 sf = 1.461
HofferQ pACD = 5.228
Haigis a0 = - 0.123, a1= 0.099, a2= 0.189
IOL Calculation for Multifocal IOLs 95
RESULTS
Table 1 shows the results of the constants’ optimi-
zation for all IOL formulas based on all available
datasets. (On the ULIB constants page,4 the results
for A, pACD and sf are rounded). Since constants
are optimized, all mean arithmetic errors ARE are
zero. Mean absolute errors ABE range from 0.33 ±
0.27 D (Holladay-1) to 0.39 ± 0.30 D (SRK II), medians
of ABE from 0.25 D (Haigis) to 0.35 D (SRK II). With
the exception of the SRK II results, the ABE medians
for all other formulas are not statistically different
from each other (pairwise multiple comparisons,
Tukey test).
Figs 1 and 2 show the axial length dependence of
the arithmetic refraction prediction error (ARE) for
all datasets, calculated with the SRK II formula9 (Fig.
1) and the Haigis formula (Fig. 2) with the ULIB
constants of Table 1. These figures illustrate the two
extremes in axial length dependence of the arithmetic
prediction error (SRK II: largest, Haigis: smallest
axial length dependence). This is a typical behavior
of the two formulas which was described in more
detail elsewhere.1
If the ULIB constants of Table 1 are applied to
the individual data of each center, the arithmetic
and absolute errors of Table 2 are obtained for the
Holladay-1 and Haigis formulas. In Figure 3, the
medians of the ABE are compared for the two
ARE [D] ABE [D]
Mean ± sd Mean ± sd Median
0.00 ± 0.42 0.33 ± 0.26 0.28
0.00 ± 0.49 0.39 ± 0.30 0.35
0.00 ± 0.43 0.33 ± 0.27 0.26
0.00 ± 0.44 0.34 ± 0.28 0.26
-0.01 ± 0.46 0.35 ± 0.30 0.25
96 Multifocal IOLs

Table 2: Mean arithmetic (ARE), mean absolute (ABE) and medians of mean absolute refraction prediction errors
obtained for different surgical centers with two IOL power formulas (Haigis and Holladay-1) and ULIB constants
Holladay-1 Haigis
ARE [D] ABE [D] ARE [D] ABE [D]
Center # Mean ± sd Mean ± sd Median Mean ± sd Mean ± sd Median
1 0.07 ± 0.40 0.33 ± 0.22 0.30 0.04 ± 0.39 0.32 ± 0.22 0.24
2 0.22 ± 0.33 0.30 ± 0.25 0.22 0.25 ± 0.30 0.30 ± 0.25 0.23
3 0.11 ± 0.32 0.26 ± 0.21 0.23 0.08 ± 0.35 0.26 ± 0.23 0.19
4 0.04 ± 0.33 0.28 ± 0.17 0.30 0.01 ± 0.35 0.29 ± 0.17 0.26
6 -0.02 ± 0.38 0.30 ± 0.23 0.25 0.00 ± 0.42 0.32 ± 0.26 0.23
5 -0.57 ± 0.64 0.72 ± 0.45 0.80 -0.71 ± 0.65 0.86 ± 0.43 0.89
all 0.00 ± 0.43 0.33 ± 0.27 0.26 -0.01 ± 0.46 0.35 ± 0.30 0.25

formulas and each center. Among these, center #5 is
easily identified as an outlier with a median absolute
error nearly 4 times as high as in the other centers.
To clarify the origin of this discrepancy, the mean
biometric (axial length and anterior chamber depth)
and keratometric (average corneal radius of curva-
ture) data from the different centers were calculated
and used to derive the average emmetropia IOL
power for each center. For this purpose, the Haigis
formula with the optimized ULIB constants was
applied. Results are compiled in Table 3 and plotted
in Figure 4. It can be easily seen that while all but
center #5 are within ≈ ± 0.6 D of the average
emmetropic IOL power of ≈ 20.9 D for all centers,
center #5 is some 2.5 D off this value. From Table 3
a considerably lower mean axial length of 22.73 ±
0.78 mm compared to the average length of 23.32 ±
0.77 mm is identified as being mainly responsible
for this effect.
To obtain the medians of the absolute errors for
scenario 2, which by definition is characterized by
center-specific IOL constants, optimizations of the
constants sf and a0 for the Holladay-1 and Haigis
formulas respectively were carried out. Results for
sf and a0 are compiled in Table3, for the mean
arithmetic, mean absolute and median absolute
errors in Table 4. Since constants are optimized, all
mean arithmetic errors (ARE) are again zero. The

Table 3: Descriptive statistical data for the different centers: numbers of patient data sets (n), axial length (AL),
anterior chamber depth (AC), mean corneal radius (CR), emmetropia IOL and lens constants sf and a0 individually
optimized for each center. *): in all cases except last: a1 = 0.4, a2 = 0.1. **): the result for a0 after single optimization
is given here only for comparison purposes; since the number of all datasets with n=339 is high enough for triple
optimization, the latter was applied, so that a0 = - 0.123, a1 = 0.099, a2 = 0.189 as in Table 3
Center # n AL [mm] AC [mm] CR [mm] Emm.IOL [D] Opt.sf Opt.a0 *)
1 35 23.54 ± 0.71 3.17 ± 0.24 7.80 ± 0.27 20.83 1.507 1.046
2 38 23.10 ± 0.52 2.76 ± 0.27 7.71 ± 0.17 21.58 1.608 1.271
3 37 23.39 ± 0.68 3.19 ± 0.22 7.76 ± 0.26 21.04 1.541 1.058
4 18 23.05 ± 0.53 3.21 ± 0.38 7.67 ± 0.13 21.54 1.490 0.977
6 188 23.40 ± 0.82 3.19 ± 0.41 7.68 ± 0.21 20.39 1.450 0.990
5 22 22.73 ± 0.78 3.16 ± 0.28 7.77 ± 0.24 23.43 1.087 0.490
**)
all 339 23.32 ± 0.77 3.14 ± 0.38 7.71 ± 0.22 20.89 1.461 0.996
 IOL Calculation for Multifocal IOLs 97

Fig. 3: Medians of absolute (ABE) refraction prediction errors for each center for the Holladay-1
(HOL) and Haigis (HAI) formulas (HAI) when the ULIB constants of Table 1 were used in each center

Fig. 4: Mean IOL power necessary for emmetropia in each center

(calculated with the Haigis formula and the ULIB constants of Table 1

ABE medians range from 0.17 D (center #3) to 0.44
D (center #5) with the Holladay-1 formula, from 0.19
D (center #2) to 0.31 D (center #3) with the Haigis
formula.
Figure 5 shows a comparison of the median
absolute errors obtained with the Holladay-1
formula when individualized or ULIB constants
were used. Center #5 has the biggest ‘advantage’ of
constants’ personalization: the median absolute error
is reduced from 0.80 D to 0.44 D (HOL) and 0.89 D
to 0.26 D (HAI). The maximum changes for the rest
of the centers are 0.06 D (HOL) and 0.12 D (HAI).
98 Multifocal IOLs

Table 4: Mean arithmetic (ARE), mean absolute (ABE) and medians of mean absolute refraction prediction errors
obtained for different surgical centers with two IOL power formulas (Haigis and Holladay-1) and lens constants (cf
Tab.3) individually optimized for each center
Holladay-1 Haigis
ARE [D] ABE [D] ARE [D] ABE [D]
Center # Mean ± sd Mean ± sd Median Mean ± sd Mean ± sd Median
1 0.00 ± 0.40 0.33 ± 0.22 0.28 0.00 ± 0.37 0.30 ± 0.21 0.25
2 0.00 ± 0.33 0.26 ± 0.19 0.20 0.00 ± 0.31 0.23 ± 0.20 0.19
3 0.00 ± 0.32 0.24 ± 0.20 0.17 0.00 ± 0.36 0.28 ± 0.22 0.31
4 0.00 ± 0.33 0.29 ± 0.15 0.32 0.00 ± 0.32 0.28 ± 0.14 0.25
6 0.00 ± 0.38 0.31 ± 0.23 0.25 0.00 ± 0.45 0.33 ± 0.30 0.24
5 0.00 ± 0.65 0.50 ± 0.41 0.44 0.00 ± 0.65 0.41 ± 0.49 0.26

all 0.00 ± 0.43 0.33 ± 0.27 0.26 -0.01 ± 0.46 0.35 ± 0.30 0.25

Fig. 5: Medians of absolute (ABE) refraction prediction errors with the Holladay-1 formula for each center when the
individualized (indiv) constants of Table 3 and the ULIB constants (ULIB) of Table 1 were used

DISCUSSION with a good chance to be less than optimum for a

given set-up. It is therefore commonly accepted
Concerning monofocal IOLs, the most frequent (35%)
e.g.11,12 that IOL constants need to be personalized
cause for lens explantations is a wrong IOL power.10
to make allowance for deviations of individual
A very obvious reason for ending up with a wrong
measurement set-ups from the average. This holds
IOL power is the use of incorrect lens constants.
especially for multifocal lenses for which
Manufacturer constants, at best, are average values,
postoperative emmetropia is mandatory.

Our results in Table1 show that with the Zeiss
IOLMaster good postoperative results can be
obtained for a multifocal IOL (Alcon ReSTOR) with
median absolute prediction errors as low as 0.25 D.
The axial length dependence of the prediction error
shown in Figs. 1 and 2 was smallest with the Haigis
and largest with the SRK II formula as known from
other studies.1 Again it is evident that SRK II should
not be used, especially not for MIOL calculation.
If the IOL constants derived from all datasets (as
published by the ULIB user group) were applied to
the individual ophthalmosurgical centers, all but one
center obtained good results, with median absolute
prediction errors between 0.22 D and 0.30 D with
the Holladay-1 and between 0.19 D and 0.26 D with
the Haigis formula (cf Table 2 and Fig.3). The center
(#5) turning out to be an outlier is characterized by
a significantly smaller mean axial length of its patient
population correspondingly necessitating a higher
IOL power for emmetropia (cf Table 3 and Fig.4).
If all centers use personalized IOL constants,
derived solely from the center-specific patient
populations, the median absolute prediction errors
are slightly better for the majority of centers, but
significantly better for center #5, for which a decrease
of the median error of nearly 50% is achieved (Table
4 and Fig. 5). Overall, median absolute errors of 0.17
to 0.44 D with the Holladay-1 and 0.19 to 0.31 D
with the Haigis formula are obtained for center-
specific constants’ customization.
CONCLUSION
For the Alcon ReSTOR MIOL good refractive results
can be obtained on the basis of IOL constants derived
from pooled datasets of different surgical centers
as they are published by the User Group for Laser
Interference Biometry. For the ULIB constants to be
applied it is however necessary that the mean axial
length or the mean emmetropia IOL power of the
patient population of a given center does not deviate
significantly from the respective values of the
statistical population underlying the ULIB constants.
If significant differences exist, a customization of lens
constants on the basis of center-specific datasets is
mandatory.
IOL Calculation for Multifocal IOLs 99
The ULB constants, in all cases, serve as a good
starting point.
ACKNOWLEDGEMENT
The author wishes to thank the following surgeons
for providing patient data:
V Centurion, MD , Brazil; R Donoso, Chile;
O Hauptman, MD , Australia; R Kaufer, MD ,
Argentina; E Suarez, MD, Venezuela; E Viteri, MD,
Ecuador.
REFERENCES
1. Haigis W. IOL calculations in long and short eyes. In:
Mastering intraocular lenses (IOLs). Ashok Garg, JT Lin
(eds), Jaypee Brothers Medical Publishers (P) Ltd, New
Delhi, India, 2007;92-99.
2. www.doctor-hill.com/iol-main.formulas.htm, as of April
26, 2007.
3. Moran JR. Optimized lens constants: influence of
diagnostic and surgical technique. Symposium on
Cataract, IOL and Refractive Surgery, American Society
of Cataract and Refractive Surgery (ASCRS), San
Francisco, CA, USA, March 18–22, 2006,
4. www.augenklinik.uni-wuerzburg.de/ulib, as of Nov 01,
2007.
5. www.doctor-hill.com, as of April 26, 2007.
6. www.augenklinik.uni-wuerzburg.de/ulib/c1.htm, as of
Nov 01, 2007.
7. Haigis W, Lege B, Miller N, Schneider B. Comparison of
immersion ultrasound biometry and partial coherence
interferometry for IOL calculation according to Haigis,
Graefes Arch Clin Exp Ophthalmol 2000; 238:765-73.
8. Holladay JT, Musgrove KH, Prager TC, Lewis JW,
Chandler TY, Ruiz RS. A three-part system for refining
intraocular lens power calculations, J Cataract Refract
Surg 1988;14:17-24.
9. Sanders DR, Retzlaff J, Kraff MC. Comparison of the
SRK II formula and other second generation formulas. J
Cataract Refract Surg 1988;14:136-41.
10. Dick HB, Tehrani M, Brauweiler P, Haefliger E, Neuhann
Th, Scharrer A. Komplikationen faltbarer Intra-
okularlinsen mit der Folge der Explantation von 1998
und 1999. Ophthalmologe 2002;99:438-43.
11. Gale RP, Saldana M, Johnston RL, Zuberbuhler B,
McKibbin M. Benchmark standards for refractive
outcomes after NHS cataract surgery. Eye advance online
publication, 24 August 2007, doi:10.1038/sj.eye.6702954.
12. Bissmann W, Haigis W. How to optimize biometry for
best visual outcome. In: Methods to achieving best
uncorrected vision for your patients. Ocular Surgery
News International Edition, May 2000, Slack Inc,
Thorofare NJ, USA, 2000;13-15.
100 Multifocal IOLs

12
IOL Power Calculation
Formulas—An Update
Ashok Garg

INTRODUCTION power which requires accurate measurement of both

the anterior (r1) and posterior radius (r2). In
Both classical and modern formulas have been used
addition, the CVF assumes paraxial ray and spherical
for the power calculation of regular IOL or
surface for the cornea and IOL. Therefore it also
accommodative IOL in aphakic, pseudophakic and
excludes the effects due to corneal surface asphericity
phakic eyes. The modern formulas include that of
change after refractive surgery.
Holladay, SRK/T, SRKI and II, Hoffer Q, Olson,
One of the major pitfalls of the existing IOL power
Haigis and the more recent formulas by Odenthal et
calculations is the ignoring of individual true corneal
al (the historical method), Aramberri et al (the double-
power and using a mean-zero error for the
K method), Rosa et al (the R-factor method) and Jin
postoperative refraction. Except the Haigis formula
et al (the Adjusted-K method). Most of these efforts
and the Lin Z 2 -formula, all other optimization
were to improve the prediction of IOL-power by a
formulas are based on one-constant like the surgeon
better prediction of the postoperative anterior
factor, the A-constant, the ACDpost or the ELP. The
chamber depth (ACDpost) or the effective lens
mean-zero error might be the result of the balanced
position (ELP) defined by ACDpre, corneal height and
errors of short and long eyes. Therefore the validity
curvature, lens thickness and axial length. All the
range of axial length for various existing formulas
existing IOL-power calculations (except Lin’s new
under a linear empirical-fit could not justify their
formulas) are based on the classical vergence formulas
accuracy when they are applied to individual eyes.
(CVF) of Fyodorov (1975), and van der Heijde (1976)
A true personalized IOL power prediction, in our
or their revision, the Hoffer Q formula (1981).
opinion, should at least individualize the following
The CVFs assume a thin-lens (for both corneal and
parameters: the postoperative ELP, axial length,
IOL) and are all based on a 2-optics system (the cornea
corneal anterior and posterior surface, and the IOL
and the IOL) which, strictly speaking, can only apply
types (or configurations).
to aphakic eyes. For pseudophakic or phakic eyes,
the 3-optics systems are much more complex and the In this Chapter, we would up-date the IOL
over-simplified 2-optics CVF suffers the following formulas and address the critical issues covering
possible drawbacks. It excludes the effects of IOL 4 subjects:
thickness and shape (configuration) and the role of 1. IOL-power
natural lens or primary IOL. Major error may result 2. Corneal power after refractive surgery
from the use of the keratometric power (Kpre or 3. Piggyback IOL power, and
Kpost) rather than the true postoperative corneal 4. Accommodating IOL.

IOL POWER FORMULAS
Theoretical Formulas
All the theoretical formulas (except Lin’s formulas)
for IOL power are based on a two lens systems, i.e.
the cornea and the pseudophakic lens focusing images
on the retina, where thin-lens is also assumed.
Table 1 summarizes these formulas.
1. Basic theoretical formulas: These include
Colenbrander’s, Fyodorov’s and Van-der-Heijde’s
formula which yield approximately the same IOL
powers.
Binkhorst’s formula yield 0.50 D stronger lens
power.
2. Modified theoretical formulas: These include Hoffer’s
formula, Shamman’s fudged formula and
Binkhorst’s adjusted formula. The fudged formula
is a modification of Colenbrander’s formula.
3. The modern formulas: These include formulas of
Haigis and Lin, where 3-constant optimization is
proposed for all ranges of eye length and IOL
types. In Lin’s new formulas, both effective ACD
and corneal power are personalized for more
accurate prediction.
Regression Formulas
These formulas are derived empirically from
retrospective computer analysis of data of patients
who have undergone surgery before. The factors on
which IOL power calculation depends are:
1. Axial length measurement: This is the most
important step in calculation of lens power. The
IOL Master is a recent method using PCI which
gives high accuracy in measurement of axial
length. An error of 1 mm affects the postoperative
refraction by (1.2 to 2.5) D approximately. It is
measured in millimeters (mm).
2. Corneal power: It is measured either in diopters or
in mm (radius of curvature).
Keratometer measures the radius of curvature
of the central part of anterior corneal surface (r1)
and given by K = 337.5/r1. All the conventional
formulas for corneal power (Kc) is given by (see
Table 2)
Kc = 1.114 K – C,
with C given by a mean value of 5.1, 5.5 or 6.5
diopter to count for the mean posterior surface
IOL Power Calculation Formulas—An update 101
power. The Lin’s formula using the personalized
p–C = 41/r1 to count for the role of individual
posterior corneal surface (r2) which may deviate
significantly from the commonly used mean value
of 6.5 mm. As pointed out by Lin, each 1.0 diopter
of corneal power would result in an error of about
(1.3 to 1.6) diopter of IOL-power calculation.
3. Postoperative anterior chamber depth (ACD): It is least
important factor in calculation of lens power. An
error of 1 mm affects the postoperative refraction
or IOL-power by approximate (0.6 to 2.5) diopter
depending on the ocular conditions based on Lin’s
M-formula.
THE ESTIMATED IOL POSITION (ELP)
The main part of highly accurate IOL power
calculation is able to correctly predict the estimated
IOL position (d = ELP) for any given patient and
IOL. Various formulas have been presented as
follows:
SRK/T,
d = A constant
Hoffer Q,
d = pACD
Holladay I,
d = surgeon factor
Holladay II,
d = ACD
Haigis,
d = aO + (a1 × ACD) + (a2 × AL)
Lin,
S = d + gT + Gp (Table 3).
In actual practice, the two eyes with same axial
length and keratometric reading may have different
lens power. This may be due to:
• Effective (or optical) lens position (S) which may
be different from the ELP (or d).
• Individual geometry of lens types.
• Presence of the natural lens or the primary-IOL.
Hoffer Q formula is best for short eyes. Holladay
for long eyes and SRK/T is best for very long eyes.
Overall SRK/T is probably most accurate in majority
of cases. It, however, ignores the role of IOL thickness
and types and only good for 2-optics aphakic-IOL like
others. The Lin’s formula is good for all axial length
and IOL types.
102 Multifocal IOLs

Table 1: For Emmetropic IOL power calculations

1. Basic theoretical formulas for emmetropia

1336 1336
Colenbrander’s formula P = L - C - 0.05 - 1336 - C - 0.05
K

1336 - LK
Fyodorov’s formula P =
1  CK
(L - C )
1336

1336 1
Van der Heijde’s formula P = –
L-C 1 C

K 1335

1336 (4R - L)
Binkhorst’s formula P = (L - C) (4R - C)

1336 1336
Lin’s S-formula (I) Z’P = (L - S) – 1336 - S
Dc
2. Modified formulas for ametropia:
1336 1336
Hoffer’s formula P = –
L  C  0.05 1336  C  0.05
KE

1336 1
Shamman’s fudged formula P = –
L  0.1(L  23)  C  0.05 1.0125  C  0.05
K 1336

1336 (4R - L)
Binkhorst’s adjusted formula P = (L  C) (4R  C)

Lin’s S-formula (II) 1336 1336

Z’P = – – QE – Pn
(see Table 3) (L  S) 1336  S
Dc

q = (1 + kP)/Z2
Z = 1 – S (Dc/1336), Z’ = 1 - p’(Pn/1336)

ACCURACY OF IOL POWER CALCULATION
In spite of recent advances in technology, there is
no single method to accurately determine the net
central power of these post-refractive surgery eyes.
The current method available is limited by lack of
clinical experience on large scale and by the theoretic
nature of all the calculation methods.
The factors, which significantly affect the accuracy
of IOL power calculations, are:
1. The error in preoperative biometry with regard
to the difference between post and preoperative
axial length measurement.
2. The position of the implantation of intraocular
lens.
3. The style of intraocular lens
4. The preoperative corneal astigmatism
5. Surgically induced corneal astigmatism
6. The postoperative astigmatism.
7. The true corneal power (post-LASIK).
 IOL Power Calculation Formulas—An update 103

Table 2: Corneal power (Dc) calculation after refractive surgery

1. Clinical-history method Dc = Kpre-RC,

RC = refractive correction of LASIK
2. Contact lens method DC = B+P+Rw-Rno
B = base curve; P = power of CL
Rw = refractive error;
Rno = bare refraction
3. Shammas method Dc = 1.114 Kpost – 6.8
4. Maloney topography method Dc = 1.114 Ktopo – 5.5
5. Koch method Dc = 1.114 Ktopo – 6.1
6. Shammas refraction method Dc = (1.114 Kpost – 6.8) – 0.23 (RC)
7. Hoffer mean-value method Dc = 337.5 (1/r1 + 1/r2)/2
8. Lin Gaussian-optics (I) Dc = 1.117 Kpost – 41/r2
(II) Dc = (377/r1)[1 – 0.109 (r1/r2)]
where
r1 = cornea front surface radius (postop)
r2 = cornea back surface radius (postop)
Kpost = postoperative keratometry
Kpre = preoperative keratometry

Table 3: Lin’s formula for IOL-power in 8. The formulas used to find IOL-power (Figs 1 and
aphakia and phakia 2).
9. Assumption of thin lens or 2-optics system.
A. 2-optics aphakia/IOL
Effective ACD: S = d + gT THE NEW GENERATION FORMULAS
Thin-IOL: d = ELP (for T = 0)
Thick-IOL: g = 1/(1+Z”P1/P2) Formulas to be detailed in the following include:
Z” = 1 – T(P2/1336) SRK (I, II), SRK/T, Hoffer Q, Holladay (I, II), Olson
B. 3-optics phakia/IOL S’ = (d + gT) + Gp’
and the more recently formulas of Haigis d-formula
p’ = p + 2.4 mm
G = 1/(1+Z’P/Pn) and Lin’s S-formula.
Z’ = 1 - p’(Pn/1336)
C. piggy back-IOL S’ = (d + gT) + g’p’
D. IOL-power (the most generalized format for 3-optics
system)
Z’P = 1336 [ 1/X – 1/Y]-Pn - q’E
X = L – S – 0.05 mm
Y = 1336/Dc – S
q’ = (1 + kP)/Z2
Z = 1 – S’ (Dc/1336)
where:
d = separation of cornea and IOL (or ELP, ACD).
p = separation of piggy back and primary IOL, or
IOL and natural lens
T = thickness of piggyback-IOL
P = IOL power (thin lens), or P1/P2 for front/back
power (thick-lens)
Pn = power of natural lens (or primary-IOL)
Dc = corneal power
E = refractive error to be corrected (on corneal plane) Fig. 1: Schematics of P vs. L for SRK formula (curve 1),
(g, G) = geometry factor for (thick-IOL, subsystem). Gaussian optics (curve 2) and Colenbrander (curve 3)
104 Multifocal IOLs

Hoffer Q Formula
The Hoffer Q formula was published in 1993 [Hoffer,
1993] and gives the IOL-power
• P = f (A, K, Rx, pACD) which is a function of:
A: axial length
K: average corneal refractive power (K-reading)
Rx: refraction
pACD : personalized ACD (ACD – constant)
Likewise, the Hoffer Q refractive error Rx
Rx = f (A, K, P, pACD), which depends on A, K,
P and pACD.
For the calculations, the corneal radii, R1C and
R2C in [mm] are converted into K in [D] according
to:
K = 0.5 (K1 + K2) with
Fig. 2: IOL-power (P) vs. corneal power (D) for a fixed ELP=4.5 K1 = 337.5/R1C and
mm for long, normal and short eyes, with L=26, 23.5 and 21
K2 = 337.5/R2C.
mm shown by curves A, B, C, respectively
The personalized ACD (pACD) is set equal to the
manufacturer’s ACD – constant, if the calculation was
SRK Formula selected to be based on the ACD – constant. In case
the A – constant was chosen, pACD is derived from
1. SRK I formula: It is basic regression formula. It is the A – constant [Hoffer, 1998] according to
given by: [Holladay et al, 1988]
P = A – 0.9K – 2.5 L pACD = ACD – const = 0.58357 * A – const – 63.896
Where P = IOL power for emmetropia
K = Keratometric power reading Holladay Formulas
A = A constant The components of the three part Holladay system
L = Axial length in mm. are:
2. SRK II formula: In this formula, the A constant is Holladay (I) formula:
adjusted to different axial length ranges. It is • Data screening criteria to identify improbable axial
given by length and keratometric measurement.
P = A1 – 0.9 K – 2.5 L • The modified theoretical formula, which predicts
A1 = adjusted constant the effective position of the IOL based on the axial
A1 = A + 3, if Axial length (L) < 20 mm length and the average corneal curvature.
A1 = A + 2, if L 20 - 21 mm • Personalized surgeon factor (PSF) that adjusts for
A1 = A + 1, if L 21 – 22 mm any consistent bias on surgeon from any source.
A1 = A, if L = 22 – 24.5 mm It is advance method, which requires patient
A1 = A – 0.5, if L > 24.5 mm refractions.
3. SRK/T formula: Regression formula for ACD (or The initial formula uses the “basic surgeon
ELP) is used to calculated IOL-power based on factor”. It can be calculated from the A-constant
Fyodorov formula. This formula is more accurate provided by lens manufacturer.
than SRK I and II. Holladay (II) formula:
ACD post = ACD – 3.336 + corneal height (H), • The IOL-power is calculated based on the
where ACD is related to the manufacturer’s A- Colenbrander or Hoffer formula for ametropic
constant by: case and it is independent to the axial length (L).
ACD = 0.62467 A – 68.747. P = Ppre – Pdesire,
 IOL Power Calculation Formulas—An update 105

• Where the preoperative and desired refractive very short eye (L<22 mm) which requires the Hoffer
power is given by (for j=1, 2, respectively): formula. Haigis 3-constant optimization allows the
Pj = 1336 / [1336/Kj – ELP], curve-fit by both parallel shift and rotation of the
• Where Kj is the corneal power calculated from curve such that it covers wider range of axial length.
the measured K-reading, Kj=1.114 K-C, C being However, the above Haigis formula also assumed
a mean power of the corneal posterior surface. thin-IOL and excludes the role of IOL configurations
for different IOL types (Figs 3 and 4).
Olson Formula
Olson proposed his 2003 regression formula for the
predicted postoperative ACD as follows:
ACDpost= ACDmean + 0.12H + 0.33ACDpre
+ 0.3T’ + 0.1L – 5.18
where H is the corneal height, T’ is the natural
lens thickness. Above formula, however, can only
apply to phakic eyes. For aphakic or pseudophakic
eyes, the coefficients will change.

Haigis Formula
It uses three constants to set both the position and
shape of a power prediction curve. The IOL
calculation according to HAIGIS is based on the
elementary IOL formula for thin lenses. Fig. 3: IOL-power vs. corneal power calculated from
d = aO + [a1 × ACD] + (a2 × AL) Gaussian optics (B), SRK-I (C) and Hoffer (A)
where
d = the effective (or optical) lens position
ACD = measured anterior chamber depth of the
eye
AL = axial length of the eye.
aO constant = same as lens constants for the
different formulas given before
a1 Constant = tied to anterior chamber depth
a2 Constant = measured axial length
Thus the value for d is determined by a function
rather than a single number.
The a0, a1 and a2 constants area derived by multi-
variable regression analysis. The Haigis formula IOL
constants will appear different than normal as they
interact with the ACD and the AL.
The conventional optimization based on one-
constant (A-constant, surgeon’s factor, ACD) which
could only “parallel shift” the calculated curve to fit
the measured data for a predicted mean zero error.
Therefore, the validation range of the axial length is
Fig. 4: Schematic comparison of various K-based formulas
limited, where improvement for long eye results more (dashed lines 1 to 4) and Gaussian-optics formulas (solid
errors for short eye, and vice versa. For example, SRK/ lines) at various corneal power for long (A) and short (C)
T is accurate for long eye (L>26 mm), but not for eyes
106 Multifocal IOLs

Lin’s S-Formula
Based on a generalized effective ACD (“S”) derived
from Gaussian optics in thick-lens for 2-optics and
3-optics system valid for all range of axial length
and IOL types. It also includes the effects due to
natural lens and primary-IOL which are totally
neglected in all the other formulas presented in
above A to E.
An effective (or optical) ACD is introduced as S
given by, for the case of thick IOL in aphakic eye,
S = ELP + gT, (1.a)
g = 1/[1+Z”(P1/P2)] (1.b)
Z” = 1-T(P2/1336) (1.c)
where T is the IOL thickness and the geometry factor
(g) is determined by the ratio of the IOL front and
back surface power P1/P2. Note that g could be
positive (for P1/P2>0) or negative (P1/P2<0).
Therefore S could be myopic or hyperopic shifted.
(Fig. 5) shows the definition of S in a 2-optics system,
where both optics can be either thin or thick lenses.
Fig. 5: Definition of effective (optical) separation (S) between
Other formulas for S are summarized in Table 3 for 2 thin lenses (A) and 2 thick lenses (B). Also shown is the
both phakic and piggyback IOL. second principal plane position (Q) and the system effective
focal length (F)
IOL POWER IN APHAKIC EYE
calculated for individual cases without the use of
This is a simple 2-optics system consisting of the “fudge factors” to fit for mean zero error (Fig. 6).
cornea and IOL (with natural lens removed). The shows the change of corneal power for various r2
IOL-power calculation based on S and the true values.
corneal power (Dc) is also developed by Lin as The individual effective ACD (the “S”) may be
follows: calculated from Eq.(1) for a given function of f(P, L,
P = 1336 / X – 1336 / Y - qE, (2.a)
X = L – S + 0.05 (2.b)
Y = 1336/Dc – S (2.c)
where q = (1+kP)/Z2 is a nonlinear term, with k about
0.003 and Z=1-S(Dc/1336). E is the remaining
refractive error after IOL implant. The above Lin’s
new formula contributes two improvements: the S
function, defined by Eq.(1) and in Table to include
the IOL configuration and the true corneal power
calculated by:
Dc = 1.117K – 41/r2, (3)
in which the true corneal power after refractive
surgery is personalized by its measured front and
back surface radius (r1 and r2). The K-reading is
further defined as K = 337.5/r1. Because that both S
and Dc are personalized, accurate IOL power may be Fig. 6: Corneal power change at various back surface

Dc, E) by solving a quadratic equation of S, similar
to the d-function of Haigis. The 3-constant
optimization like Haigis, but using S rather than d,
allows us to obtain the minimal mean error not only
for all range of axial length (L), but also for all IOL
types via the g-factor in Eq.(1). Greater details of
above issues will be presented in other Chapters of
this book.
IOL POWER IN PHAKIA AND PIGGY-BACK-IOL
For phakic IOL or piggy-back IOL, the IOL power
calculations involve with a 3-optics system which has
been recently formulated by Lin by generalizing the
Eq.(2) of 2-optics (aphakic-IOL) as follow:
Z’P = 1336/X – 1336/Y - q’E – Pn (4)
which has the following revisions to count for the
effects from the presence of the natural lens or the
primary IOL (having a power Pn) and the separation
between the cornea and IOL (ACD or ELP); and IOL
and natural lens or primary-IOL (p).
a. A reduction factor Z’ = 1-p’ (Pn/1336), with p’ =
p + 2.4 mm, is introduced and has a value of Z’=
0.95, for p’=6.0 mm for a typical phakic-IOL
implanted in front of a natural lens power of 21 D
and separated by p=1.0 mm or p’=1.0+2.4=3.4 mm.
In comparison, Z’ is about 0.99 for the case of
piggy-back IOL (with p’=p=1.0 mm). Therefore
a reduction of about 5% and 1% is expected in
the IOL-power term (Z’P).
b. A new S’=S + Gp’ is introduced, with a system
geometry factor given by
G = 1/[1+Z’(P/Pn)] (5)
where P and Pn are the IOL-power and the
natural lens (or primary-IOL) power, respectively.
The above system geometry factor (G) may be
compared to the IOL geometry factor given by
g=1/[1+Z”(P1/P2)], with Z”=1-T(P2/1336) and
for thick-IOL case S=ACD+gT. Therefore
S’=ACD+gT+Gp’, for the general case of thick-IOL
implanted in phakic (or primary-IOL) eye.
c. A new nonlinear term q’ is introduced and given
by
q’ = (1+kP)/Za2, (6.a)
Za = 1-S’ (Dc/1336), (6.b)
which reduces to the 2-optics (aphakia) q’=q,
when p’=0, S’=S and Z’=Z as expected. The new
IOL Power Calculation Formulas—An update 107
3-optics Za may be further related to the Z in 2-
optics aphakic-IOL by
Za = Z - Gp’ (Dc/1336), (7)
where the second term is due to the shifted
distance of the second principal plane of the IOL-
natural lens or piggy-back-IOL and primary-IOL
subsystem.
d. Conversion function (CF), one may define Zeff
derived from Zeff2 = Z’Za to obtain
Zeff = 1 – Seff (Dc/1336), (8.a)
Seff = S + 0.5p’ (Pn/Dc), (8.b)
where Seff is defined as the shifted S by an amount
proportional to p’ and the power ratio (Pn/Dc) of the
natural lens or primary-IOL(Pn) and the cornea (Dc).
For typical values of p’ = 3.0 mm, Pn = 20 D, Dc = 43
D, one obtains Seff = S + 0.7 mm. This 0.7 mm shift
may result in IOL-power difference about (0.7/S)2
or about 3% to 5%, for S = 3 to 4 mm.
Above Eq.(8) allows us to calculate a conversion
function (CF), defined by
CF = -(dE/dP) which may be derived from the
deviative of Eq.(4) and using Eq. (8) as follows:
CF = 1-2k’E)Zeff2, (9)
Therefore the CF in 3-optics is lower due to the
natural lens (or primary IOL) about 5 to 10% less
than 2-optics formula. In other words, the
conventional 2-optics formulas overestimate the IOL-
power when it is implanted in phakia or
pseudophakia, but simplified as aphakia. Greater
details will be shown in other Chapter of this book
by Lin.
Piggy-back IOL Power
Given the CF, the piggy-back IOL power to correct
a residual ametropia power (E), on the corneal plane
(not spectacle plane), may be calculated by
P = E/CF, (10)
where CF is given by Eq.(9) in general.
Comparison of various formulas is shown in Table 4.
Several critical issues on the previous formulas may
be addressed as follows:
a. All the formulas, except Lin’s, are based on the
spectacle power (E) converted to IOL-power (P).
The Es of Lin is defined as E on the corneal plane.
Another new formula for spectacle-power
conversion to corneal plane is also presented in
other Chapter of Lin in this book.
108 Multifocal IOLs

Table 4: Piggy-back IOL-power (P) formulas for residual ametropia error

1. Sanders and Kraff (1980) based on empirical data of over 2500 IOL lens
P = E/0.67=1.49 E
2. Feiz and Mannis (2001) P = E/0.7 = 1.43E
3. Holladay II (1993) P = (IOL)1- (IOL)2
based on Hoffer (1981), (IOL)j = 1336/[1336/Kj-ELP]
Colenbrander (1973) Kj (j=1,2), for pre- and postoperative corneal power
for plus IOL, P(+) =1.5E,
for minus IOL, P(-) = 1.0E;
E is the postop refractive error at spectacle plane.
4. Shammas (2001) P = (E/a)/(138.3-A)-0.5
where a = 0.03 for plus IOL,
a = 0.04 for minus IOL.
A = A-constant = (ACD+63.896)/0.5836
5. Gills (1996) only for hyperopic correction
P(+) =1.4E+1.0
6. Lin (2005) P = Ec/(CF) = (1.25 to 1.7) Ec
The Z2-formula * CF = (1-2kE)(Ec/Z2)
for both plus and minus IOL. Z =1-S(Dc/1336)
Typical value: CF = (0.6 to -0.8)
where:
Dc is the corneal power and k is a nonlinear term.
S is the effective (optical) lens position, S=ELP+gT+ Gp’
E (Ec) is the refractive error on the spectacle (corneal) plane and may be related by
another conversion factor Ec=E/Zs2, with Zs=1-0.012E.
* For simplified 2-optics system, see Eq.(9) in the text and Table 3 for 3-optics system

b. Formulas of Sanders-Kraff and Feiz-Mannis are
comparable. However, both are based on a mean
value of CF= 0.7 which may be valid only for
average clinical data. Individual CF value could
be 10% to 20% deviate from this mean value and
would require Lin’s formula.
c. Gills formula is only good for hyperopia and it is
also based on average case.
d. Shammas formula might be good for low IOL
power, say 5.0 D or less. It includes the dependence
of ACD (or the a-constant). However, it does not
include the effects due to corneal power or
individual IOL types. It also assumes thin IOL and
a 2-optics system or aphakic IOL.
e. Holladay II is based on Colenbrauder including
the effect of ELP and corneal Power. It needs
numerical method versus the analytic formula of
Lin which also revises ELP by S.
Both Holladay II and Lin’s formula for P are
independent to the axial length (L) and only
depend on the ACD (or ELP) or S.
f. Lin’s new formula based on Gaussian optics
might be the only one which includes most of
the effects due to individual ocular parameter
and IOL types, where the effective ACD (S, or
Seff) has been rigorously defined for various
systems of aphakic, aphakic or pseudophakic and
for both thin and thick IOL. The roles of natural
lens or primary-IOL are also included in the new
formula.
ACCOMMODATING IOL (AIOL)
The accommodating rate function (M) defined as the
accommodation amplitude increase per 1.0 mm
forward movement of a plus AIOL may be
expressed by the Lin’s M-formula (Fig. 7).
M = (Z/1336)P[2Dc+ZZ’P], (11)
Above formula is a general form for both phakia
and aphakia and also for dual-optics AIOL. As shown
in Figure 8, for the thick-IOL single-optics case, the
M value is higher for convex-concave IOL

Fig. 7: Accommodation rate (M) vs. IOL-power in single-
optics IOL at various configurations
Fig. 8: IOL-power (P) vs. axial length (L) for a fixed corneal
power Dc=43 diopter at various IOL position ELP=3.5, 4.5
and 5.5 mm shown by curve (A), (B) and (C), respectively
configuration (having front and back surface power
of P1 and P2) which has higher P1 for a given P1+P2,
when P2<0 (concave). Depending on ocular
conditions, M ranges from 0.5 to 2.5 (D/mm) for
AIOL-power of 10 to 20 diopters. Greater details of
IOL Power Calculation Formulas—An update 109
single-optics and dual-optics AIOL may be found in
other Chapters of Lin in this book.
CONCLUSION
The existing IOL-power (except Lin’s) based on 2-
optics system could only apply to aphakia. For phakia
or piggyback IOL, a 3-optics system based on
Gaussian optics is required. The Lin’s new formulas
provide more accurate calculations for both phakia
and aphakia presented by:
• The S-formula (to include IOL thickness and
types).
• The Seff-formula (to include the role of natural
lens and primary-IOL).
• The personalized r2-formula (including corneal
posterior surface power post-LASIK).
• The M-formula (for accommodating IOL
efficiency).
• The Z2-formula (for conversion of IOL-power in
3-optics system of phakia or piggyback IOL).
Greater details of above formulas may be found
in other Chapters of Lin in this book.
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 13
Premium Presbyopia—
Correcting IOLs
The sun is setting on the old mindset of cataract
surgery. The old paradigm is that of elderly patients
with dense cataracts who don't mind wearing glasses
after surgery. The new age of cataract surgery
involves younger patients with milder cataracts who
have an expectation of freedom from glasses for
most activities.
Every year our technology and surgical techni-
ques get better and better. Compare the phacoemul-
sification machines from a decade ago to the modern
marvels we use now. The same applies for our
intraocular lens (IOL) technology. Within the next
10 years or less, we will have IOLs that provide a
much larger amplitude of accommodation, superb
image quality, and highly accurate refractive results.
To perform premium IOL surgery we need to
embrace the concept that cataract surgery is
refractive surgery. We must provide excellent
refractive results and treat our patients like luxury
consumers. Improving our cataract surgical skills is
crucial and I offer the following pearls.
ACHIEVE POSTOPERATIVE REFRACTIVE
ACCURACY
Precise IOL calculations are the foundation for
improved refractive accuracy. Every effort should
be taken to use optical methods of axial length
determination. For cases where an optical measure-
ment is difficult or impossible, immersion A-scan
ultrasonography should be employed. The tradi-
tional method of applanation ultrasonography can
Uday Devgan
be highly inaccurate and is operator dependent. An
error of just 0.3 mm can result in a 1-diopter (D)
refractive surprise postoperatively.
Using the most precise technology to measure
the axial length is not enough. We must also
personalize our A-constants to achieve consistency.
Keeping track of postoperative refractive results and
then comparing the expected outcome versus the
actual outcome will help us to hone our lens
calculations. In calculating the IOL power, it is critical
to use a newer-generation theoretical formula
(Hoffer Q, SRK-T, Holladay 1 and 2, Haigis) and
not a regression formula. There is evidence that a
specific IOL formula may be more accurate for a
subset of eyes. There are also multivariable formulas,
such as the Holladay 2 and Haigis, which may
produce more accurate results once personalization
is achieved (Fig. 1).
Fig. 1: Based upon the work of Ken Hoffer MD, the IOL
calculation formula can be customized to the axial length of
the eye
116 Multifocal IOLs
The determination of the true keratometric value
is usually straightforward, but it can be more
difficult in post-corneal refractive surgery eyes. In
these patients, dozens of methods to estimate the
corneal power have been described, which means
that none of these methods is perfect. It is typically
best in these eyes to err on the side of myopia and
to make sure that the patient understands the high
probability of ametropia and the possible need for
an enhancement to achieve the desired postopera-
tive refractive goal.
The cataract surgeon needs to have a method of
fixing postoperative refractive surprises. For most
small degrees of ametropia, corneal excimer laser
refractive surgery is the best option because it is
accurate, less invasive, and can be performed in the
clinic. Other options include the use of piggy-back
IOLs or even IOL exchange. For cataract surgeons
who do not currently perform corneal refractive
surgery, it may be wise to pair up with a corneal
refractive surgeon.
REDUCE PREEXISTING CORNEAL
ASTIGMATISM
Every incision made into the cornea has the potential
of affecting the astigmatism. For your routine
cataract surgery, what is the effect of your incision?
For most surgeons using a 2.5 to 3.0 mm self-sealing
corneal incision, there is a flattening effect of about
0.25 to 0.50 D at the axis of the incision. If the patient
has a small amount of preexisting corneal astigmatism
at the site of your planned incision, it will work out
well. However, a considerable percentage of patients
will have significant corneal astigmatism that needs
to be specifically addressed.
Learning to use limbal relaxing incisions (LRIs)
at the time of cataract surgery is an effective way to
reduce the preexisting corneal astigmatism and
achieve postoperative emmetropia (Fig. 2). Topo-
graphy is the most effective way to properly under-
stand the extent of the corneal astigmatism and will
make your LRI planning more accurate. Excellent
nomograms and instructions are available from some
of the pioneers of LRIs, including Louis D. "Skip"
Nichamin, MD, Doug D. Koch, MD, and Jim P. Gills,
MD , among others.
Fig. 2: Slit-lamp photo of a limbal relaxing incision at the
90 degree meridian
Because correction of preexisting corneal
astigmatism is not a covered benefit of Medicare
and most insurance plans, patients pay out of pocket
for LRIs and similar procedures. Practicing the
technique of LRIs as well as honing your own LRI
nomogram will help you deliver consistent results.
FIX POSTOPERATIVE REFRACTIVE SURPRISES
It is not always possible to achieve postoperative
emmetropia. There are variations in lens calculations,
lens labeling, lens position, and patient healing. In
these patients, it is helpful to have methods to
address postoperative refractive surprises. For small
spherical residual refractive errors, implanting a
piggy-back IOL into the ciliary sulcus is an easy
option for most cataract surgeons.
Corneal refractive surgery can be a very accurate
way to correct residual refractive errors. For
postoperative hyperopic surprises, use of conductive
keratoplasty (CK; Refractec, 5 Jenner, Suite 150.
Irvine, CA 92618 USA) is a viable option that is
well within the skill set of most general
ophthalmologists. For those with access to an
excimer laser, surface ablation or laser in situ
keratomileusis (LASIK) is very accurate. For
surgeons without excimer access, I suggest teaming
up with a local refractive surgeon.
START WITH CATARACT PATIENTS FIRST
For your first few refractive IOL patients, start with
patients that have very significant cataracts (Fig.3).

Fig. 3: Patients with dense cataracts are more tolerant of
residual refractive errors of dysphotopsias since their pre-
operative vision is so poor. They often say that "Anything is
an improvement"
When the patient's preoperative vision is 20/100 or
worse, they tend to be happy by just clearing their
visual axis. As one patient put it, "Anything is an
improvement!" These patients already have problems
with acuity, contrast, glare, halos, and color
perception, so that even a complicated surgery by a
first-year resident would likely result in an
improvement in vision.
Once you feel that you have honed your refractive
results, consider performing refractive lens exchange
on precataract patients. These patients already have
vision that is correctable to 20/20 or close to it, and
as such, they will be far more demanding of precise
postoperative results.
CHOOSE THE RIGHT INITIAL PATIENTS
To further stack the odds in your favor, choose initial
patients who are hyperopic with low amounts of
corneal astigmatism. These hyperopes are reliant on
glasses for all distances preoperatively and
elimination of spectacles for even part of their visual
needs is a huge improvement for them.
Patient personality is also a factor. A perfectionist
mentality is fine for the surgeon, but is best avoided
in the patient. I tell patients that these IOLs are not
the fountain of youth and that no surgery can make
them see like teenagers again. Having an easy-going
mindset goes a long way towards achieving
postoperative satisfaction for both the patient and
the surgeon.
Premium Presbyopia—Correcting IOLs 117
Fig. 4: Using phaco power modulations, the total ultrasonic
energy used to remove even a dense cataract can be reduced
dramatically
DELIVER CLEAR CORNEAS
Refractive surgery patients want clear vision, and
that requires clear corneas. It is just not acceptable
to routinely induce corneal edema, Descemet's folds,
and massive inflammation from surgery. Techniques
to protect the corneal endothelium and minimize the
phaco energy must be employed (Fig. 4). Good-
quality viscoelastics, mechanical nucleus disassembly
via phaco chop, and phaco power modulations are
all helpful in achieving consistently clear corneas
immediately after surgery.
MINIMIZE COMPLICATIONS—
SOFT IRRIGATION AND ASPIRATION
If you perform exactingly accurate IOL calculations,
reduce the corneal astigmatism, remove the cataract
with minimal phaco energy, but then break the
capsular bag during cortex clean up, the refractive
result has been jeopardized. One of the most
important new innovations in cataract surgery has
been the development of the silicone-coated soft
irrigation and aspiration (I&A) tip (MicroSurgical
Technologies, Redmond, WA) (Fig. 5), which
prevents any metal to capsule contact. The silicone
tip is far gentler to the posterior capsule than steel,
and in my hands this tip has not damaged a single
capsule in hundreds of cases.
118 Multifocal IOLs
Fig. 5: The silicone-coated soft I/A tips prevent metal-to-
capsule contact and may decrease the incidence of posterior
capsule rupture during cortex removal
PREVENT CYSTOID MACULAR EDEMA—
NONSTEROIDAL ANTI INFLAMMATORY DRUGS
There are now multiple published studies that
conclusively show that the perioperative use of
topical nonsteroidal anti-inflammatory drugs
(NSAIDs) is important for the prevention and
treatment of cystoid macular edema (CME). The
selection of one brand of NSAID over another is the
subject for another article, but you should clearly be
using your choice of NSAID for all cataract and lens
surgery patients.
It's hard to explain to a patient why they don't
see well, even though you chose the optimum IOL,
you eliminated their astigmatism, and you
performed excellent surgery. Preventing CME is as
important as preventing intraoperative complica-
tions.
CHOOSE THE RIGHT INTRAOCULAR LENS
There are currently three refractive IOLs that
address presbyopia that are approved by the Food
and Drug Administration (FDA). They are the
ReZoom from Advanced Medical Optics (Santa Ana,
CA), the Crystalens from Eyeonics (Aliso Viejo, CA),
and the ReSTOR from Alcon (Fort Worth, TX). Each
of these IOLs addresses presbyopia differently and
they work in different ways. The surgeon must
understand these differences and evaluate patients
to determine if they are appropriate candidates for
each IOL option. I have found that patients truly
do need time to adapt to these new IOLs and that
the period of neuroadaptation may take months.
UNDERPROMISE AND OVERDELIVER
Our goal for any refractive surgery is primarily to
meet or exceed the patient's expectations. Making
sure that patients have a realistic expectation of the
limits of refractive IOL surgery is important, as no
surgery is perfect. A 65-year-old patient does not
expect a plastic surgeon to make her look 25 years
old again; rather she expects to look better. Similarly,
we need to help our 65-year-old patient understand
that she will not be able to see as she did when she
was 25 years old; rather we will help her see better.
Premium Intraocular Lenses in Patients with
Prior Refractive Surgery
Patients who undergo refractive surgery have a
desire to improve their unaided vision and decrease
their dependence on glasses. This personality trait
remains throughout their life and when they develop
cataracts in the future, they will still want to maintain
a large degree of freedom from spectacles.
Performing cataract surgery in these patients is more
complex due to the difficulty in intraocular lens (IOL)
calculations, the issues of visual quality and higher-
order aberrations, and the high level of patient
expectations.
IOL Selection
Patients who have undergone prior corneal
refractive surgery often have induced higher- order
aberrations in their corneas as well as a degree of
irregularity. This is particularly true in patients with
prior radial keratotomy and those who have
undergone high degrees of excimer-based laser
correction. For this reason it is imperative to perform
corneal topography to determine the amount of
corneal irregularity. Wavefront aberrometers are
helpful in determining the degree of higher-order
aberrations.
Use of a multifocal IOL, either refractive or
diffractive, involves intentionally creating aberra-
tions in order to provide a greater range of

uncorrected vision via multifocality. In normal virgin
eyes multifocal IOLs reduce contrast sensitivity.
Combining a multifocal IOL with an irregular or
highly aberrated cornea can create an excessive loss
of image quality. Patients who have undergone mild
to moderate degrees of excimer-based laser
correction, typically in the form of laser in situ
keratomileusis (LASIK) or photorefractive
keratectomy (PRK), tend to have relatively regular
corneas with reasonable degrees of higher order
aberration. These patients are suitable candidates
for a multifocal IOL.
Patients who had undergone prior radial
keratotomy (RK), particularly those with hexagonal
cuts, more than 8 radial cuts, and small optical zones,
tend to have high degrees of corneal irregularity.
Patients who previously had aggressive excimer
corneal ablations to treat high degrees of ametropia
usually have excessive levels of higher-order
aberrations and may even have early corneal ectasia
and thinning. These patients are not good candidates
for multifocal IOLs. Instead, an accommodating IOL
or even a monofocal IOL may be a better choice.
One advantage of an accommodating IOL is that
the accommodative amplitude can allow for more
variance in the accuracy of the lens calculations. For
example, should the patient end up somewhat
hyperopic after surgery, they are able to use some
of their accommodative amplitude to focus at
distance. This is similar to performing LASIK surgery
in a 25-year-old patient—a slight over-correction
resulting in mild hyperopia is of little concern
because these patients can accommodate in order to
achieve a plano refractive result.
Aspheric IOLs may be a particularly good choice
for post-myopic LASIK patients due to their
significant corneal aberrations. Implanting a negative
spherical aberration aspheric IOL can help to off-set
the large amount of positive spherical aberration
often seen in RK corneas. When the corneal
aberrations are not known and a degree of irregu-
larity and other higher order aberrations are sus-
pected, I prefer an IOL with zero spherical aberration
because it will not confound the aberrations.
IOL Power Calculation
In this subset of patients who desire the most
accurate postoperative results, the lens calculations
Premium Presbyopia—Correcting IOLs 119
are the least predictable. This is due to the corneal
changes induced by the prior corneal refractive
surgery.
Many formulas and techniques have been descri-
bed for calculating IOL power in post-RK patients-
this tells me that there is no single method that yields
great results. The principle error in calculation in
previously myopic patients is over-estimation of the
corneal power, which results in implantation of a
lower power IOL, with a resultant post-operative
hyperopia. Because these patients have typically been
myopic their entire life, leaving them with residual
hyperopia is particularly uncomfortable and
bothersome. To help prevent postoperative hyper-
opia, a more myopic result can be targeted such as
–0.75 D instead of the typical –0.25 D.
In patients with no old records, the method that
I use most often to calculate corneal power was
initially proposed by Robert Maloney, MD and later
revised by Doug Koch, MD and Li Wang, MD.1 It
uses the central corneal power as measured by
topography and therefore does not depend on prior
history or records. The power of the cornea is a
combination of the anterior corneal power and the
posterior corneal power. By converting the overall
central corneal power from topography back to the
anterior corneal power, then subtracting the expected
posterior corneal power, we can achieve a fairly
accurate estimation for our IOL calculations. This
formula is:
Estimated K power = (Central K power on topo
376/337.5) – 6.1
Intraoperative Considerations
When creating the clear corneal incision during the
cataract surgery it is important not to damage the
LASIK flap. Care should be taken to initiate the
incision closer to the limbus so that it avoids
contacting the corneal flap.
In patients with prior RK, the old incisions are
weak and are prone to opening during surgery. Any
incisions made during cataract surgery must avoid
intersecting the pre-existing RK incisions, lest they
unzip and cause excessive fluid leakage during
surgery. In patients with previous 8-cut RK (Fig. 6),
clear corneal incisions can be made between the
existing RK incisions. In patients with 16-cut or more
120 Multifocal IOLs
RK (Fig. 7), it becomes very difficult to avoid the
existing RK incisions unless a scleral tunnel cataract
incision is used.
To be gentle on the weakened cornea, I prefer
using a lower aspiration flow rate and a lower bottle
height, with a smaller phaco needle to ensure that
fluid inflow remains greater than fluid outflow. If
the RK incisions open during surgery, be aware that
there could be sudden instability and shallowing of
anterior segment and the chance for posterior capsule
rupture is increased. At the end of these surgeries, I
like to paint the entire cornea with fluorescein dye
to check for any leaks, which can easily be sutured
while the patient is in the operating room.
In patients with prior phakic IOL surgery, this
lens implant must be removed prior to starting the
cataract surgery. I strongly recommend using two
separate incisions, both of which are placed on the
steep axis. The first incision is to remove the phakic
IOL and the second incision is to perform the cataract
surgery (Fig. 8A). The first incision should be sutu-
red to ensure a water-tight anterior chamber dur-
ing phacoemulsification. The second incision should
be placed in the meridian that allows for the greatest
ease of performing the cataract surgery (Fig. 8B).
Postoperative Management
The LASIK flap can swell during the postoperative
period, causing some refractive instability. RK
incisions swell during even the gentlest cataract
operation and this swelling can induce central corneal
flattening, which results in excessive hyperopia
immediately postoperatively. These RK patients will
experience fluctuations in their refractive state for
many weeks after their cataract surgery, so a mild
amount of initial hyperopia should not be a cause of
concern. After waiting at least 6 weeks for the
keratometry readings to return to their preoperative
level, if the patient is still significantly hyperopic, a
second procedure can be performed. Note that the
corneas in RK patients will continue to become
progressively flatter in the years to come, with a
slow shift toward hyperopia.
The primary determinant of the patient's post-
operative refractive spherical state is the effective
lens position of the IOL after surgery. This is complex
because the patient's healing response and level of
fibrosis and capsular contraction after surgery are
largely unknown. I explain to patients that my calcu-
lations and my surgery assume that they will have
an average healing response, but if they heal more
or less aggressively than normal, I may need to
perform a second touch-up procedure to help them.
They understand this and they appreciate that the
surgeon is willing to do whatever it takes. In our
practice, this is included at no additional cost to the
patient, so it gives the practice an incentive to be as
accurate as possible in IOL calculations. Because
enhancements are necessary in only a small
percentage of patients, this has a mild impact on the
practice finances.
In post-LASIK eyes, where the IOL selection is
more estimation than calculation, doing an
enhancement after IOL surgery is not difficult
because the prior corneal flap can be lifted. In other
patients, I prefer to wait at least a couple of months
until the cataract incisions have fully healed before
performing LASIK to fine tune their refractive status.
In cases where there is a very high likelihood of
needing to perform LASIK enhancement following
the IOL surgery, a corneal flap can be created prior
to the intraocular surgery. In post-RK eyes,
performing a piggy-back IOL may be a better choice
in order to avoid inducing any further corneal
irregularities or weakening.
Perhaps the most important issues in refractive
surgery patients with cataracts are explaining to
them that their IOL calculations are, at best,
estimations, and that their surgery and post-
operative recovery will likely be more challenging
for both the surgeon and the patient.
Implanting Premium IOLs in Patients with
Compromised Capsular Support
Performing premium intraocular lens (IOL) surgery
requires premium visual results, and that typically
requires a premium anatomic result. Because the
capsular bag and zonular apparatus is responsible
for fixating and centering the lens implant and for
coupling with the ciliary muscle, in the case of
accommodating lenses, every effort must be taken
to achieve proper positioning and fixation.

Fig. 6: Cataract incisions in 8-cut RK patients. Clear corneal
incision can be used as long as they are placed between the
existing RK incisions without intersecting them
Fig.7: Cataract incisions in 16-cut RK patients. A scleral
tunnel incision should be used for the cataract surgery since
it will not intersect any of the many existing RK incisions
Fig. 8A: A: Preoperative configuration showing the phakic
IOL and the cataract. B: De-enclavating the phakic IOL from
the iris. C: Making a nasal clear corneal incision at the steep
axis. D: Removal of the phakic IOL via the nasal incision
Premium Presbyopia—Correcting IOLs 121
Fig. 8B: A: The nasal incision is sutured closed. B: Phacoe-
mulsification of the cataract via a temporal clear corneal
incision at the steep axis. C: Insertion of the posterior
chamber IOL. D: Checking all incisions with fluorescein dye
Monofocal or multifocal IOLs require good
centration, fixation, and placement within the
posterior chamber. Accommodating IOLs require the
same level of placement but they must also be
coupled to the ciliary muscle for optimum function
and maximum accommodative amplitude. Capsular
weakness, a ruptured posterior capsule, or a large
errant capsular tear usually precludes the use of an
accommodative IOL but may still allow the use of
fixed-position refractive IOLs. For this reason, we
will limit our initial discussion to fixed-position
refractive IOLs, with a special section devoted to
accommodating IOLs at the end of this chapter.
Anterior Capsular Tears/Radialization
A well-centered, continuous, curvilinear capsulorr-
hexis of an appropriate size helps to keep the IOL
within the capsular bag. However, if the capsulorr-
hexis is irregular or there is a radial tear, most
refractive IOLs can still be implanted. Care should
be taken to retrieve the errant tear and complete a
continuous capsulorrhexis without having the tear
extend to the zonules or beyond. The refractive IOL,
both fixed as well as accommodating, can now be
placed within the capsular bag with the haptics
oriented 90° away from the errant tear. These
patients tend to do well with few postoperative
122 Multifocal IOLs

problems related to the errant anterior capsulorr- leading to uveitis, glaucoma, and iris defects, if
hexis. placed in the ciliary sulcus. The traditional method
is to place the entire 3-piece IOL into the sulcus. This
Posterior Capsule Rupture will necessitate using a lower IOL power due to the
When the posterior capsule ruptures during cataract more anterior resting position of the lens (Fig. 10).
surgery, the patient is at risk for many sight- If there is a well-centered anterior capsulorrhexis,
threatening complications. Retinal complications such the IOL haptics can be placed within the sulcus and
as breaks, detachments, and macular edema are of the optic captured behind the capsulorrhexis. This
major concern. Additionally, these patients are more allows for more secure fixation as well as a more
prone to endophthalmitis due to the loss of the accurate postoperative refractive result. This is the
barrier function of the posterior capsule. preferred technique in cases of a posterior capsule
The surgeon's primary goals when a posterior rupture (Fig. 11).
capsule rupture is detected are to minimize further
damage to the capsule, to limit vitreous prolapse,
and to prevent posterior displacement of lens
fragments. Once the eye has been stabilized and the
anterior segment is found to be free of lens material
as well as any prolapsed vitreous, options for IOL
placement can be evaluated by the surgeon.
If the posterior capsule rupture is limited and a
continuous, central, posterior capsulorrhexis can be
performed, then the IOL can be placed within the
capsular bag (Fig. 9).
If the posterior capsule rupture is irregular, then
it is better to place the IOL in the ciliary sulcus. Note
that only 3-piece fixed-position refractive IOLs
should be placed within the sulcus and that any Fig. 10: Placement of the entire IOL, both haptics and optic,
single-piece IOL, particularly acrylic ones, should in the ciliary sulcus in the presence of an open posterior
capsule
not be placed in the sulcus. These single-piece acrylic
IOLs can cause iris chaffing and pigment dispersion,

Fig. 9: Placement of the entire IOL, both haptics and the Fig. 11: The haptics are in the ciliary sulcus and the optic is
optic, within the capsular bag in the presence of a posterior captured through the anterior capsulorhexis into the capsular
capsular opening bag. This allows for very secure fixation of the IOL
 Premium Presbyopia—Correcting IOLs 123

Weak and Missing Zonules

Certain ocular conditions, such as pseudoexfoliation
or trauma, can result in weak or missing zonules,
which can compromise the proper positioning of the
refractive IOL. Depending on the degree of zonular
instability, there are options for IOL positioning.
If there is a small, focal area of zonular loss, then
the IOL can still be placed within the capsular bag,
with care taken to ensure that the IOL haptics are
positioned at the axis of the zonular loss. This will
allow the spring action of the haptic to bolster the
capsular equator (Fig. 12). Fig. 12: IOL placed in the capsular bag with the haptic at the
area of zonular loss to bolster the support at the equator
The IOL, if it is of the 3-piece variety, can also be
placed in the ciliary sulcus, but with the haptics
oriented 90° away from the area of focal zonular
loss. The IOL power will need to be adjusted
downward due to the more anterior placement of
the optic (Fig. 13).
If the zonular weakness or loss is more extensive,
then a capsular tension ring can be placed within
the bag to distribute force evenly over the entire
capsular equator. The IOL can then be placed within
the capsular bag without any adjustment to the
calculated IOL power (Fig. 14).
For diseases with progressive zonular loss, there Fig. 13. IOL placed in the ciliary sulcus with the haptics
exists the possibility that the IOL, even with proper oriented 90° away from the area of zonular loss, which tends
initial positioning or use of a capsular tension ring, to move inwards due to lack of support
will become displaced and decentered. This will
result in markedly decreased performance. In these
cases, it may be more prudent to implant a monofocal
IOL, particularly one with zero spherical aberration,
as its optical performance is relatively insensitive to
decentration.

Accommodating Intraocular Lenses

Due to their need to be coupled to the ciliary muscle,
accommodating IOLs require more meticulous
attention to detail during surgery as they must be
placed within the capsular bag for optimum function.
Fig. 14: IOL placed in the capsular bag after insertion of a
A mild to moderate irregularity in the anterior capsular tension ring which distributes force over the entire
capsulorrhexis would still allow in-the-bag capsular and addresses the large area of zonular loss
implantation of an accommodating IOL, but care
should be taken to orient the haptics away from this A posterior capsule rupture usually means that
area. A large anterior capsule irregularity will likely the accommodating IOL cannot be placed. The
cause difficulty with long-term stability of an exception is for a small, central rupture that can be
accommodating IOL. converted into a posterior capsulorrhexis, which is
124 Multifocal IOLs
smaller than the optic diameter and is completely
covered by the optic. This is rarely achieved and
most posterior capsule ruptures will preclude the
use of these IOLs.
Similarly, a large defect in the zonular support
structures is a contraindication to use of an
accommodating IOL because it will not be possible
to couple the IOL to the ciliary muscle and the
expected accommodative amplitude will be quite
low. With a small, focal defect, it may be possible to
implant the accommodative IOL in the capsular bag,
though this may negatively affect performance.
Although the vast majority of our planned
refractive cataract surgeries go as planned, there will
be instances where there is an errant capsular tear,
a posterior capsular rupture, or significant zonular
disruption. In many of these cases, we can still
implant a presbyopia-correcting IOL and achieve a
good visual outcome. However, in other situations
the damage may be so significant that the intended
IOL cannot be safely and securely implanted in the
eye. For this reason, as part of our routine preopera-
tive discussion, we need to alert the patient to the
slim possibility that the intended IOL may not always
be the one implanted at the time of surgery.
Postoperative Management of
Patients with Presbyopic IOLs
Patients who elect to receive presbyopia-addressing
refractive intraocular lenses (IOLs) tend to be
younger with milder cataracts and they may be
paying a premium for their surgery. These patients
have higher expectations and they want to quickly
recover sharp vision at a variety of distances without
complications.
The postoperative management of these patients
actually begins before surgery, during the pre-
operative consultation when the patients must be
educated and their expectations understood. If the
postoperative course and visual recovery are
discussed in detail with the patients prior to the
surgery, they will be more satisfied and more realistic
in their expectations.
Timeline of Healing and Visual Recovery
It's helpful to provide the patients with an
approximate timeline of their anticipated visual reco-
very. They may not realize that they need time to
adapt to pseudophakic vision, particularly when
multifocal or accommodating IOLs are used.
Although the patient may recover reasonably good
vision the day after surgery, a total of 4 to 6 weeks
is needed to achieve capsular contraction and
refractive stability.
Even though, as ophthalmologists, we went to
medical school, completed an internship, and learned
full-body anatomy, how many of us know the
timeline of healing after arthroscopic knee surgery?
Can you walk and put pressure on the leg after
1 week? 3 weeks? 3 months? When will the brace be
removed? When can you resume exercise? These
simple questions would seem too basic to an
orthopedic surgeon, but to the patient, they are
important and the answers are unknown.
Similarly for our patients, we need to tell them
when their vision will stabilize, when they will be
able to read well, how much light they will need to
optimize near vision, and when they can resume
activities.
The initial recovery of vision is usually very rapid,
with most patients seeing relatively well the same
day or the day after the surgery. In cases of a dense
cataract, where more phaco energy is used and some
corneal edema is anticipated, explaining the need
for a week or two to recover initial vision is crucial.
With multifocal IOLs, there is a period of neuro-
adaptation where the brain and visual system needs
to adapt to the new way of seeing-intraocular image
rivalry, with 2 or more distinct images from different
focal points focused on the retina at once. As the
neuroadaptation progresses, patients become more
comfortable with their new vision and their percep-
tion of side effects, such as glare, halos, and dys-
photopsias, tends to diminish.
With accommodative IOLs, there is also a period
of adaptation as the eye and ciliary muscle complex
become functionally able to move the IOL in
response to an accommodative stimulus. This process
may take weeks to months.
Minimize Complications
In order to achieve optimal visual results, we need
to minimize the potential postoperative compli-
cations. This includes the prevention of subclinical
cystoid macular edema (CME), which has been
shown to occur in a significant percentage of routine

cataract surgeries. The development of CME in the
postoperative period will cause decreased visual
acuity and a reduction in contrast sensitivity and
the quality of vision. In patients with multifocal IOLs,
where there is already a compromise in their contrast
sensitivity, even mild CME can be severely
detrimental to their vision. Use of topical
nonsteroidal anti-inflammatory drugs (NSAIDs) in
the postoperative period has been shown to decrease
the incidence of subclinical CME. For this reason,
many surgeons use NSAIDs routinely for all patients
undergoing cataract or refractive lens surgery.
The most common complication after routine
cataract surgery is the development of posterior
capsule opacification (PCO). With refractive IOLs,
even mild amounts of PCO are detrimental to the
visual performance of the lens implant. Multifocal
IOLs split the light going into the eye, which results
in decreased contrast sensitivity. Adding any opacity
to the posterior capsule makes this even worse. For
accommodating IOLs, care must be taken to ensure
that the capsular contraction does not cause a
misalignment or shift in the position of the IOL. In
addition to performing a capsulotomy to treat any
PCO, there may be a need to perform anterior
capsule relaxing incisions with the yttrium-
aluminum-garnet (YAG) laser to prevent capsular
phimosis.
Postoperative Refractive Status
Determining the perfect IOL power for a specific
patient is not always easy, particularly if the patient
has had prior corneal refractive surgery. In these
cases, there may be a need in the postoperative
period to fine-tune the refractive result of the eye.
Patients should be aware of the potential need for a
second surgery or enhancement to achieve a specific
refractive goal. This may be in the form of further
corneal refractive surgery, a piggy-back IOL, or
Premium Presbyopia—Correcting IOLs 125
perhaps even an IOL exchange. Refractive IOLs
require optimal refractive results, and this may mean
an additional surgical procedure.
Encouragement and Feedback for Patients
Finally, we need to spend time giving the patient
feedback and encouragement during the post-
operative period. With accommodating IOLs, the
near vision requires effort from the ciliary muscle.
For most patients, the ciliary muscle has not been
used to focus their crystalline lens for decades.
Therefore, when it is called upon to focus the new
IOL, there is often a feeling of fatigue. This fatigue
resolves with time and the near vision improves as
the ciliary muscle regains strength. When certain
visual milestones are reached, patients should be
congratulated on their new vision.
BIBLIOGRAPHY
1. Borasio E, Mehta JS, Maurino V. Torque and flattening
effects of clear corneal temporal and on-axis incisions
for phacoemulsification. J Cataract Refract Surg. 2006;
32:2030-38.
2. Gills JP. Treating astigmatism at the time of cataract
surgery. Curr Opin Ophthalmol. 2002; 13:2-6.
3. Kaufmann C, et al. limbal relaxing incisions versus on-
axis incisions to reduce corneal astigmatism at the time
of cataract surgery. J Cataract Refract Surg. 2005; 31:2261-
65.
4. Nichamin LD. Nomogram for limbal relaxing incisions. J
Cataract Refract Surg. 2006; 32:1408.
5. O’Brien TP. Emerging guidelines for use of NSAID
therapy to optimize cataract surgery patient care. Curr
Med Res Opin. 2005; 21:1131-37.
6. Wang L, Booth MA, Koch DD. Comparison of intraocular
lens power calculation methods in eyes that have
undergone LASIK. Ophthalmo-logy 2004;111(10):1825-
31.
7. Wang L, Misra M, Koch DD. Peripheral corneal relaxing
incisions combined with cataract surgery. J Cataract
Refract Surg. 2003; 29:712-22.
126 Multifocal IOL’s
14
Mixing and Matching IOLs:
Options and Results
INTRODUCTION
If one described the perfect IOL, it would include
perfect quality vision without aberrations or contrast
loss, seamless accommodation from distance to near,
absence of dysphotopsias or posterior capsule
opacification, and no loss of function with time.
Unfortunately, no such IOL exists. Every currently
available lens has benefits and disadvantages. Because
of this, it may sometimes be useful to combine lenses
of different types in a single patient to enhance their
outcome, the overall goal being to maximize vision
and to reduce unwanted side effects.
To best use complimentary ("mix and match")
intraocular lenses it is important for the ophthalmo-
logist to understand the strengths and weaknesses
of each intraocular lens.
AVAILABLE IOLs: STRENGTHS AND
WEAKNESSES
The standard monofocal intraocular lens is the best
economic value. It gives excellent distance, fair
intermediate and poor near vision. For example 20/
20+, J4, J7 at the three distances. The pseudo-
accommodative amplitude is approximately 2
diopters which means it has about 1 diopter of
pseudoaccommodative amplitude to the minus side.
This means that if the patient is targeted for a –1.50
refractive outcome they will be able to read as though
they had a +2.00 to +2.50 reader. The lens has positive
spherical aberration of approximately +0.10 microns,
somewhat dependent on optic power and optic
design. This type of spherical aberration is best in
Elizabeth A Davis, Richard L Lindstrom
patients who have negative spherical aberrations in
the cornea such as those posthyperopic LASIK, with
keratoconus or a cornea with naturally occurring
negative spherical aberration (10-20%).
Second, we have aspheric monofocal intraocular
lenses including those with no spherical aberration
(B and L Advanced Optic) and those with negative
spherical aberration (AMO Tecnis, Alcon IQ). The
intraocular lens with no spherical aberration is most
forgiving of decentration and tilt, and might be
selected in patients where decentration might occur
such as in pseudoexfoliation, a capsular tear or where
an ideal capsulorhexis is not available.
The implants with negative spherical aberration
give better quality of vision, especially mesopic vision
in the patient with a typical cornea with positive
spherical aberration. They also provide superior
performance in the patient that has undergone
myopic refractive surgery.
The accommodating intraocular lens as designed
by Eyeonics and called the Crystalens gives excellent
distance and intermediate vision. Typically one can
achieve 20/20+ and J1 at distance and intermediate
respectively. It provides good near acuity with a
typical outcome being J3 or better. This lens has the
least night vision symptoms, the least loss of contrast
sensitivity and the least color distortion of all
presbyopia correcting intraocular lenses. It is also
pupil size independent in its optical function. It is
excellent for blended vision.
The zonal aspheric multifocal intraocular lens
manufactured by AMO and called the ReZoom
provides good distance acuity, good intermediate
 Mixing and Matching IOLs: Options and Results 127
acuity, and good near acuity. Typical outcomes are
20/20 distance, J2 intermediate and J2 at near. There
are some night vision symptoms, some loss of contrast
sensitivity and some color distortion. This lens is pupil
size dependent.
The aspheric diffractive multifocal intraocular lens
(AMO Tecnis Diffractive Multifocal Intraocular Lens)
provides good distance acuity, fair intermediate and
excellent near acuity. Typical outcomes to be expected
are 20/20- at distance, J4 at intermediate and J1 at
near. It also has the potential for night vision
symptoms, decreased contrast sensitivity and some
color distortion. The decreased contrast sensitivity
usually associated with a multifocal implant is
reduced by the aspheric nature of the optic.
The apodized diffractive/refractive multifocal
intraocular lens (Alcon Restor) provides good
distance acuity, fair intermediate and excellent near.
Distance acuity might be expected to be 20/20-,
intermediate J4 and near J1. This lens also potentially
generates night vision symptoms, decreased contrast
sensitivity and color distortion. It is also pupil size
dependent as the lens becomes more distance
dominant as the pupil dilates.
MIX AND MATCH OPTIONS
There are presently 3 main categories of IOLs:
monofocal (spheric, aspheric, and toric),
accommodative, and multifocal. Amongst these
lenses, there are 5 basic mixing combinations possible.
The first combination is the use of 2 monofocal IOLs
with differing focal points to achieve monovision. This
can be a very successful option, particularly in
patients who have worn such a correction in contact
lenses. The exact focal point of the near eye can be
chosen to suit the patient's needs. Targeting myopia
of 1.0 D to 1.75 D allows for functional intermediate
vision, whereas a target of 2.0 D to 2.5 D provides
true near vision. The monovision approach requires
neuroadaption with suppression of the near eye when
gazing at distant objects and suppression of the
distance eye when focusing up close. The greater the
disparity between eyes, the more difficult it is for the
patient to adapt. Nevertheless, there is the benefit of
maintaining high quality of vision with the monofocal
optics. Pseudophakic monovision is a good option in
patients who have the potential for development of
eye diseases that impact contrast sensitivity
(glaucoma, macular degeneration, diabetic retino-
pathy, etc). It is also a good option in an eye which
has undergone keratorefractive surgery (excimer
laser ablation, incisional keratotomy, etc.) where
corneal irregularities may already impact contrast
acuity and visual quality.
The second mixing combination is a monofocal
IOL with an accommodating IOL. This option
provides excellent distance and intermediate vision
and fairly good near vision (J3). If some myopia is
targeted in the eye with the accommodating IOL, a
stronger near point can be achieved, albeit with some
sacrifice of distance acuity in that eye. This
combination may be particularly useful when the
patient has had prior lens surgery in one eye with a
monofocal IOL and desires enhanced near vision in
the second eye without sacrificing quality. This
approach maintains high quality of vision with
monofocal optics. It, too, is a good option in patients
at risk for eye diseases or who have previously
undergone corneal refractive surgery.
A third combination is a monofocal IOL with a
multifocal IOL. Here, both eyes can achieve excellent
distance vision with the added benefit of some
pseudoaccommodation in the multifocal eye. The
ReZoom multifocal IOL provides excellent
intermediate vision and good near vision whereas the
Restor IOL provides excellent near vision but minimal
intermediate vision. As with all multifocal IOLs, there
is a chance for glare, haloes and reduced contrast
acuity. However, most patients find these symptoms
to diminish with time. Additionally, should they
occur, their presence in only one eye may be
mitigating.
The fourth option for mixing IOLs involves an
accommodative IOL with a multifocal IOL. This is
similar to the third option described in terms of
quality of vision, but with even enhanced inter-
mediate vision.
Lastly, one can mix 2 multifocal IOLs of differing
types. Many surgeons find this useful when the
patient seems to be comfortable with and adaptable
to multifocal optics but has a strong desire for
improving both uncorrected intermediate and near
vision. Mixing a ReZoom and Restor IOL can achieve
this result.
128 Multifocal IOL’s

For all of these combinations it is imperative to
treat any pre-existing conditions that may impair
vision. This includes treatment or management of lid
malposition, blepharitis, dry eye, and anterior
basement dystrophy. Intraoperatively, attention to
IOL centration/positioning is particularly important
with the toric, accommodating, and multifocal IOLs.
Improper positioning of these IOLs may not only
reduce their effectiveness, but may impair the visual
outcome. Techniques that reduce the incidence of
PCO and capsular phimosis (adequate capsulorhexis
size, symmetric capsular shape, meticulous cortical
cleanup, and capsular optic overlap) are also impor-
tant. Use of nonsteroidal anti-inflammatory eye
drops for several weeks postoperatively may prevent
CME, which even in subtle forms can impair contrast
acuity. A plan to treat any corneal astigmatism of
0.75 D or greater is often required. If a toric IOL is
not used, then incisional keratotomies, laser excimer
ablation, or conductive keratoplasty should be
considered.
As always, to achieve optimal outcomes for any
of these choices, preoperative patient counseling is
critical. The surgeon should understand the patient's
needs and preferences. Additionally, the patient
Table1
ReZoom/ReZoom ReStor/ReStor
(N=100) (N=100)
Bilateral uncorrected distance 20/20 20/25
Bilateral uncorrected intermediate J2.15 J3.85
Bilateral uncorrected near J2.30 J1.40
Average reading speed 125 165
(words per minute)
Spectacle independence 75% 89%
Halos/glare 2+ 1+
MTF 0.20 0.12
should be made aware of the limitations of all of
these choices and the potential compromises and side
effects. The patient should be informed of the
potential need for additional enhancement surgeries
and the associated costs and risks.
OUTCOMES WITH MIX AND MATCH
Select recent clinical series of mix and match with
some multifocal and accommodating intraocular
lenses provide insight into the outcomes that might
be obtained. Leonardo Akaishi, MD and Pedro Paulo
Fabri, from Sao Paulo, Brazil have performed a
comparative series of ReZoom/ReZoom, ReStor/
ReStor, ReZoom/ReStor and Tecnis Diffractive/
ReZoom. Their outcomes are summarized in Table 1.
The best outcomes were obtained with ReZoom/
Restor and ReZoom/Tecnis Diffractive Intraocular
Lens combinations.
Rick Milne, MD from Columbia, South Carolina
has also performed a comparative series looking at
patient satisfaction, spectacle independence and day
time and night time halo. His outcomes are
summarized in Table 2. Again, the ReZoom/ReStor
outcomes generated higher patient satisfaction than
the ReStor/ReStor outcomes in this series.
ReZoom/ReStor ReZoom/Tecnis
(N=88) Diffractive (N=15)
20/20 20/20
J2.30 J2.10
J1.50 J1.10
155 185
100% 100%
1+ 1-
0.18 0.38

Table 2

ReStor/ReStor (N=30+) ReZoom/ReStor (N=30+)

Satisfied/very satisfied 83% 96%
Neutral dissatisfied 0 4%
Very dissatisfied 17% 0%
Would have procedure again, recommend to family and friends 70% 97%
Complete spectacle independence 65% 94%
Day time halo 43% 18%
Night time halo 86% 71%
Requesting explants 6% 0%
 Mixing and Matching IOLs: Options and Results 129

Frank A Bucci, Jr. MD from Wilkes-Barre, ReStor use in alternate eyes. Again, he found
Pensylvania has also completed a series comparing excellent distance, intermediate and near vision with
ReStor/ReStor to ReZoom/ReZoom. His outcomes high patient satisfaction.
are summarized in Table 3. Of note, is that his
intermediate vision outcomes are significantly better Crystalens/ReStor
(N=32)
with ReZoom/ReStor than with ReStor/ReStor and
that his patient satisfaction is also higher. Bilateral uncorrected distance 20/25
Finally, Trevor Woodhams, MD from Atlanta, Bilateral uncorrected intermediate J1.3
Bilateral uncorrected near J1.3
Georgia has a series of patients with Crystalens/

Table 3

ReStor/ReStor (N = 55+) ReZoom/ReStor (N = 39 +)

Bilateral uncorrected distance 20/25 20/25 (P=NS)
Bilateral uncorrected intermediate J3.81 J2.39 (P.001)
Bilateral uncorrected near J1.00 J1.04 (P=NS)
Unhappy with intermediate 32% 0%

CONCLUSION authors. The choice of which IOLs to use depends

upon patient lifestyle, preference and personality.
Mixing IOLs is a known and successful strategy for Until the “perfect” IOL is developed, mixing IOLs
many patients. All of the above combinations have will remain a useful strategy for correcting vision
been performed with excellent outcomes by the for our patients.
 15
Personal Experiences with the
Single Optic 1 CU and the Synchrony
Dual Optic Accommodative IOLs
The last step in successful cataract or lens removal
surgery is the restoration of accommodation. 1,5,7
Several single-optic systems have been introduced
on the market. In Germany the 1 CU IOL
manufactured by Humanoptics AG (Erlangen,
Germany) came on the market as single optic IOL
based on Patents by Hanna (Fig. 1). Several studies
in Europe have shown certain limitations for these
IOLs based on the anterior shift principle. Those
lenses need movements of around 1.5 to 2.5 mm to
achieve 3 diopters of accommodation.1-5,7,8,10 Even
though the lens showed satisfactory clinical results,
Fig. 1: Intraoperative photo of an 1CU accommodative IOL
GU Auffarth
the amount of accommodation measured never
exceeded 0.75 to 1 diopter, indicating a big range of
pseudoaccommodative parameters (such as residual
refraction, myopia, astigmatism, pinhole effect of
pupil, corneal refractive changes, etc.).
Personal experiences with several hundred 1 CU
implantations indicated very satisfactory clinical
results with absolutely no patient complaints and
no IOL exchanges. Even though PCO-rates were
high after 3 to 4 years postoperatively the IOL never
showed any tilt or haptic problems resulting from
fibroptic reactions of the capsular bag. The
advantages of having no glare or halos or other
photic phenomena is on positive aspect of single optic
accommodative IOLs. However controlled studies
and measurements with the AC-Master in
cooperation with W. Haigis clearly proved that the
1 CU IOL is not moving on average than 70-100 μm
(Fig. 2). Thus resulting in a very limited range of
accommodation.
On the US-Market the Crystalens AT 45 was
actually FDA approved and widely used. Apart from
visual acuity results no objective means for
accommodative measurements were presented in the
peer reviewed literature. Studies in Europe by Findl.
and co-workers indicate a similar performance of
this single optic IOL like the 1CU.8
A dual-optic design offers potential advantages
over single-optic designs in that less lens movement
is necessary with the dual optic to achieve a certain
amount of accommodation (Fig. 3).3,5,7,9 For example,
in order to achieve 2.0 D of pseudo-accommodation,
134 Multifocal IOLs

increase their distance from each other, resulting in

increased effective power of the overall lens. The
Sarfarazi IOL is now under evaluation by Bausch &
Lomb.13 No clinical data have been presented so far.
The Visiogen Synchrony accommodative IOL
consists of a high power (30 Dptr.) anterior optic
and a variable minus power posterior optic (Fig. 4).
It is made of Silicone material. Implantation of the
first generation models were done with folding
forceps. The latest generation has now an injector
for implantation (Fig. 5).

Fig. 2: Graphical illustration of the ACD-Change in relation to

uncorrected near visual acuity (UCNVA) with the 1CU-IOL

a 22-D single-optic IOL would need to move forward

1.6 mm within the capsular bag. A dual-optic IOL
with a +30-D front lens and a –8-D posterior lens
(overall power = 22 D) would only require 0.8 mm
of separation to achieve 2.0 D of power change
(Fig. 3).
Two dual optic IOLs are currently tested. The
Sarfarazi Elliptical Accommodating IOL and the
Visiogen Synchrony lens (Fig. 4).1-5,7-10,13 Both utilize
a plus-powered biconvex front lens connected to a
negatively powered concave-convex lens. During the
accommodative effort the two lens components A

B
Fig. 3: Graphical illustration of the accommodative effect in
relation to amount of optic shift of single and dual optic Figs 4A and B: Clinical retroillumination photograph and
systems still picture of the Synchrony IOL
 Personal Experiences with the Single Optic 1CU & the Synchrony Dual Optic Accommodative IOLs 135

A B C
Figs 5A to C: Injector system for Synchrony IOL

The Synchrony IOL as been extensively studied
in laboratory (rabbit) models as well as in multi-
centre clinical trials in Europe and Latin America.
Clinical data are available with a 3-4 years follow
up now.1-5,7,9,11,12 The lens is also now CE-marked
in Europe and therefore available for clinical use.
The first clinical generation of the Synchrony dual
optic accommodative IOL showed over a 2-3 years
follow up period good functional results, stable
refraction and low to mediocre PCO development
(Fig. 6). Interlenticular opacification (ILO) was the
main concern regarding these dual-optic IOLs. To
date, however, this has not been reported as a
complication of these IOLs. Studies of the IOL in
rabbits suggest that the design features of the
Synchrony may help prevent posterior and anterior
capsule fibrosis. In another study in rabbits the
incidence of ILO was zero, also indicating that the
lens material (silicone) may prevent interlenticular
lens epithelial cell migration.11,12
Ossma and coworkers could demonstrate by
ultrasound biomicroscopy movements between the
two IOLs of up to 0.6 to 0.8 mm (Fig. 7 and 8). The
residual near addition to reach J1 was around 0.78
diopters and UDVA and UNVA was in all cases >20/
40. 5,7

1 month 24 months

Fig. 6: Retroillumination photograph of Synchrony IOLs with a 24 months follow-up.

Only small amount of PCO, no ILO
136 Multifocal IOLs

UBM: Pat. MGR. 3 months postoperative

Distance focus Difference: 0.59 mm Near focus

Fig. 7

UBM: Pat. LBB. 6 months postoperative

Distance focus Difference: 0.80 mm Near focus

Fig. 8

Figs 7 and 8: Ultrasound biomicroscopy of Synchrony IOL indicating

movement between lenses of 0.59 (Fig. 6) and 0.80 mm (Fig. 7)
 Personal Experiences with the Single Optic 1CU & the Synchrony Dual Optic Accommodative IOLs
Dick et al. and Auffarth et al presented similar
results with the early Synchrony model. 3,5,7 In
contrast to single optic designs the dual optic designs
offer theoretically and practically the chance of a
real accommodative effect. Several questions still
need to be scientifically evaluated. The IOL
calculation or in other words the exact location of
the IOL inside the capsular bag is difficult to predict
or to determine. The prevention of posterior capsule
opacification (PCO) is still a longterm concern. New
instruments such as the “perfect capsule” system by
Milvella Inc. (Sydney, Australia) offer nowadays new
means to target the elimination of lens epithelial cells
(LEC). 6
In summary the dual optic IOLs seem to be the
most effective design or IOL type achieving a
significant amount of accommodation. Other (new)
concepts in accommodative IOLs include the
Powervision Fluidvision IOL, which is capable of
curvature changes to achieve accommodative
changes or the smart lens, a lens refilling device
consisting of a thermoplastic material.
New clinical studies especially with the now
clinically approved Visiogen Synchrony IOL will
show how successful these dual optic designs on the
market will be.
REFERENCES
1. Auffarth GU. Accommodative intraocular lenses. Can
synthetic lenses accommodate? Ophthalmologe
2002;99(11):809-10.
2. Auffarth GU, Martin M, Fuchs HA, Rabsilber TM, Becker
KA, Schmack I. Validity of anterior chamber depth
measurements for the evaluation of accommodation
after implantation of an accommodative Humanoptics
1CU intraocular lens. Der Ophthalmologe 2002;99;815-
19.
3. Auffarth GU, Reuland AJ, Entz BB, Holzer MP. First
experiences with a dual optic accommodative IOL. In
137
Pham DT, Auffarth GU, Wirbelauer C, Demeler U (Eds):
Transactions: 18. Congress of the German Society for
IOL Implantation and Refractive Surgery, Biermann
(Publ.), Cologne, 2004;285-88.
4. Auffarth GU, Schmidbauer J, Becker KA, Rabsilber TM,
Apple DJ. Miyake-Apple video analysis of movement
patterns of an accommodative intraocular lens implant.
Der Ophthalmologe 2002;99;811-14.
5. Auffarth GU. Accommodative intraocular lenses. In
Pham DT, Auffarth GU, Wirbelauer C, Demeler U (Eds):
Transactions: 18. Congress of the German Society for
IOL Implantation and Refractive Surgery, Biermann
(Publ.), Cologne, (2004)239-44.
6. Rabsilber TM, Limberger IJ, Reuland AJ, Holzer MP,
Auffarth GU. Long-term results of sealed capsule
irrigation using distilled water to prevent posterior
capsule opacification: a prospective clinical randomised
trial. Br J Ophthalmol 2007;91(7):912-5.
7. Dick HB. Accommodative intraocular lenses: Current
status. Curr Opin Ophthalmol 2005;16(1):8-26.
8. Findl O, Kiss B, Petternel V, Menapace R, Georgopoulos
M, Rainer G, Drexler W. Intraocular lens movement
caused by ciliary muscle contraction. J Cataract Refract
Surg 2003;29(4):669-76.
9. McLeod SD, Portney V, Ting A. A dual optic accommo-
dating foldable intraocular lens. Br J Ophthalmol
2003;87(9):1083-5.
10. Vargas LG, Auffarth GU, Becker KA, Rabsilber TM,
Holzer MP. Performance of the Accommodative 1 CU
IOL in Relation with Capsulorhexis Size. J Cataract
Refract Surg 2005;31:363-68.
11. Werner L, Pandey SK, Izak AM, Vargas LG, Trivedi RH,
Apple DJ, Mamalis N. Capsular bag opacification after
experimental implantation of a new accommodating
intraocular lens in rabbit eyes. J Cataract Refract Surg
2004;30(5):1114-23.
12. Werner L, Mamalis N, Stevens S, Hunter B, Chew JJ,
Vargas LG. Interlenticular opacification: dual-optic versus
piggyback intraocular lenses. J Cataract Refract Surg
2006;32(4):655-61.
13. Sarfarazi FM. Sarfarazi dual optic accommodative
intraocular lens. Ophthalmol Clin North Am
2006;19(1):125-8.
 16
First Experiences with the Rayner
Aspheric, Toric, Multifocal
Intraocular Lens (M-Flex-T)
GU Auffarth

INTRODUCTION high hyperopia between +6 to +10 diopters and

astigmatism between -3 and -4.75 diopters. One
Cataract surgery with intraocular lens (IOL)
patient was myopic (-6 and -8 diopters and
implantation has developed markedly over the past
astigmatism around -3 diopters. Refractive lens
15 years. Special lens implants included multifocal
exchange was performed via phacoemulsification
IOL designs, aspherical IOLs and toric implants. For
using the Alcon Infiniti System. It was uneventful.
all specialized IOLs it is critical that the implant has
The implanted IOL was a Rayner C-flex 588F with
a stable fixation in the capsular bag. 1,6,7 Neither
+3.0 dpt. near addition. The multifocal IOL Design
decentration nor rotation of the IOL should occur.
is based on the Rayner M-Flex, a refractive MIOL
One contraindication against multifocal IOL
with +3 Dptr.
implantation is a corneal astigmatism of more than
Near addition and aspherical intermediary zones,
1.5 diopters.4,5
which can improve depth of focus and can minimize
The authors have extensive experience and
contrast loss.
expertise in multifocal and toric IOL develop-
ment.1-4 As principle and co-investigators in the FDA
trials for the Rayner Centerflex and C-flex models
the authors were very familiar with the basic
platform of that implant and helped to develop the
toric T-Flex IOL.3
In these cases presented here a new lens type
was developed combining optical principles of a
multifocal, aspherical and toric IOL to subsequently
cure different types of ametropia simultaneously.
To our knowledge these were the fist IOL prototype
implanted worldwide:

PATIENTS AND METHODS

In 4 patients aged between 45-54 years 6 aspherical
toric multifocal IOLs were implanted for refractive
lens exchange purposes. Those IOLs were custom
made by Rayner UK, Ltd., In 4 eyes there was a Fig. 1: Schematic drawing of the Intraocular lens
 First Experiences with the Rayner Aspheric, Toric, Multifocal Intraocular Lens (M-Flex-T) 139

Fig. 2A to D: Implantation sequence of the implant: (A) IOL before implantation, (B) IOL inside the injector, (C) Injection/
implantation of IOL into the lens capsular bag, (D) IOL in the eye at the end of surgery

RESULTS
The patients underwent successful refractive lens
exchange in general anesthesia via clear cornea
incision and phacoemulsification in their eyes.
The UDVA one month postoperatively was 0.5
to 0.9 and the UCNVA was 0.5 to 0.7. Photic
phenomena were not reported by the patients.

Fig. 3: Defocus curve of the M-Flex T MIOL
CONCLUSIONS
This is the first IOL prototype implanted worldwide
combining different optical principles in one IOL
type. Patients’ functional results, subjective satis-
faction and tolerance were very good. The addition
of a fixed torus to a multifocal IOL platform will
140 Multifocal IOLs
facilitate and increase the numbers of selectable
patients for multifocal IOL implantation.
REFERENCES
1. Becker KA, Auffarth GU, Volcker HE. Measurement
method for the determination of rotation and
decentration of intraocular lenses. Ophthalmologe
2004;101 (6):600-3.
2. Becker KA, Holzer MP, Reuland AJ, Auffarth GU:
Accuracy of lens power calculation and centration of an
aspheric intraocular lens. Ophthalmologe 2006;103(10):
873-6.
3. Becker KA, Martin M, Rabsilber TM, Entz BB, Reuland
AJ, Auffarth GU: Prospective, non-randomised, long-
term clinical evaluation of a foldable hydrophilic single-
piece intraocular lens: Results of the Centerflex FDA
study. British Journal of Ophthalmology 2006;90(8):971-
4.
4. Holzer MP, Rabsilber TM, Auffarth GU: Presbyopia
correction using intraocular lenses. Ophthalmologe
2006;103(8):661-6.
5. Lane SS, Morris M, Nordan L, Packer M, Tarantino N,
Wallace RB 3rd. Multifocal intraocular lenses. Ophthalmol
Clin North Am 2006;19(1):89-105.
6. Negishi K, Ohnuma K, Ikeda T, Noda T. Visual simulation
of retinal images through a decentered monofocal and a
refractive multifocal intraocular lens. Jpn J Ophthalmol
2005;49(4):281-6.
7. De Silva DJ, Ramkissoon YD, Bloom PA. Evaluation of a
toric intraocular lens with a Z-haptic. J Cataract Refract
Surg 2006;32(9):1492-8.
 17
Bilateral ReZoom Implantations:
Personal Experience
Multifocal intraocular lenses (IOLs) are one of the
newer treatment strategies for patients with cataract
and concurrent presbyopia, as well as for patients
who have not yet developed cataract but are
presbyopic. For the cataract or refractive surgeon,
there are multiple options available for the patient,
including bilateral refractive IOLs, bilateral diffractive
IOLs, or bilateral accommodating lenses. Mixing
refractive and diffractive IOLs, mixing accommo-
dating and multifocal IOLs, or even an aspheric
monofocal IOL with monovision or mixed with
accommodating or multifocal IOLs are additional
options.
Our personal preference in most patients is
bilateral implantation of a refractive IOL (ReZoom,
AMO, Santa Ana, Calif.). However, there are some
patients in whom other lens strategies, or even mixing
different lenses based on patient feedback may be
more advantageous. Ophthalmologists no longer can
take a “one size fits all” approach to cataract surgery,
but must weigh the options and available lenses for
each patient, individually.
This chapter will address how to evaluate a patient
to determine if he/she is a candidate for multifocal
IOLs, and if so, how to best match the lens to the
patient’s needs, desires, and expectations.
Which Patients should we Choose for a
Multifocal IOL?
We have found in our clinical practice that patient
satisfaction seems to revolve mainly around the
degree of motivation a patient has to achieve spectacle
David R Hardten, Parag D Parekh, Mona Fahmy
independence. Because there are trade offs with
quality of vision and independence from spectacles a
strong motivation to reduce dependence on glasses
is necessary to help the patient tolerate the visual side
effects. A recent meta-analysis looked at all clinical
trials that compared a multifocal lens to a monofocal
lens (used as controls) to try to determine if the benefit
of good vision at all ranges outweighed the optical
compromises inherent in the multifocal lenses. The
results suggest that these multifocal lenses are
effective at improving near vision relative to their
monofocal counterparts, and confirmed our
observation that patient satisfaction seemed to
revolve around a motivation to achieve spectacle
independence.1
Patients that tend to tolerate multifocal IOLs from
the psychological standpoint tend to be older (in the
Medicare age group), tend to be optimistic in general,
and do not drive a lot at night. From a clinical
standpoint, those who are presbyopic low hyperopes
with cataract tend to be easier to please because they
gain in both best corrected vision and uncorrected
distance and near vision. Younger, more active
patients have the highest expectations from their
surgery, and while they are more motivated to have
decreased dependence on spectacles after IOL
surgery, they are more difficult to please. Low
myopes are used to having good uncorrected near
vision, and while they typically can adapt to the
multifocal IOLs, may be more difficult to please at
near, especially if spectacles are their primary mode
of vision correction. Patients with only mild cataract
142 Multifocal IOLs
or those with a clear lens may take longer to adapt
to the extra glare or halo of a multifocal IOL. High
hyperopes and high myopes without retinal
pathology tend to do quite well because they are
gaining both uncorrected distance and near, yet the
IOL calculations may be more challenging in this
group of patients.
Importance of Preoperative Work-up
We have found preoperative measurements are
especially crucial in calculating the power accuracy
for a multifocal lens. The five data points that are
important before proceeding with a multifocal IOL
implantation are: desired postoperative refraction,
average K readings, axial length, anterior chamber
depth, and the lens constant. Topography is helpful
for understanding the corneal symmetry. We
typically use manual keratometry with a calibrated
keratometer, while other surgeons may also use
automated keratometry or topography derived
corneal power measurements. Immersion ultrasound
with the Prager Shell (ESI, Inc., Minneapolis, MN)
or optical coherence biometry with the IOL Master
(Carl Zeiss Humphrey, Dublin, CA) is preferred over
contact ultrasound. The anterior chamber depth
measurements are probably more accurate with
immersion ultrasound. In general we use the SRK-T
formula for calculating normal to long eye IOL
measurements, and in shorter eyes, the Holladay II
formula has worked well.
Once the patient has been determined to clinically
be acceptable for implantation of a multifocal lens,
subjective factors take the forefront and may lead me
to dissuade someone from using a multifocal IOL,
who on clinical examination appeared ideal. There is
typically an adjustment period with multifocal IOLs
for patients and those who are impatient, or deem
themselves perfectionists, are often not willing to
work through the adjustment period – and they may
leave your office unhappy.
Initially, at our offices, we give all potential
multifocal IOL candidates a patient questionnaire that
helps identify whether they are interested in reducing
their dependence on glasses after cataract surgery.
The questionnaire also evaluates whether they are
willing to accept the potential unwanted visual
phenomena such as glare or halo as a trade off for a
reduction in the amount of time they wear glasses.
Bilateral ReZoom Implantation
Not every patient with cataracts and/or presbyopia
is ideal for a multifocal IOL. Among the factors that
reduce the ability to gain a good result with a
multifocal IOL: unstable capsular support, corneal
scarring, severe dry eye, small pupils, or monofocal
implants in the first eye are all factors that have
potential to reduce the acceptance and function of
these lenses.
As mentioned earlier, there are several multifocal
IOL alternatives; my personal preference in most
patients is to bilaterally implant a refractive IOL (the
ReZoom). Refractive lenses offer excellent inter-
mediate and distance vision and no degradation of
light transmission when the pupil is small. The optical
properties of the lens have incoming light directed
across the whole focal plane of the lens, which gives
the patient good vision at all distances. These lenses
do tend to be pupil-dependent, however, and patients
may have night vision symptoms. I find patients with
medium-size mobile pupils fare the best.
The Optical Properties of the ReZoom
The ReZoom lens is based on AMO’s Array platform,
and uses hydrophobic acrylic biocompatible material,
whereas the Array was based on a silicone platform.
AMO has coined the phrase “balanced view optics”
to explain how the lens works.
The ReZoom has five circular “zones”, propor-
tioned to provide good visual function across the
range of distances under varying light conditions
(Fig. 1). The first zone is in the center of the lens, and
is a large, distance-dominant central zone for bright
light situations. Zone 2 is only slightly smaller,
concentric around the first zone, and provides
additional near vision in a broad range or moderate-
to-low light conditions. Zones 3-5 have decreasing
diameters, with zone 3 a distance zone for moderate-
to-low light conditions, zone 4 a near-dominant zone
for near vision across a range of light conditions, and
zone 5 a low-light/distance-dominant zones for low-
light conditions (night driving, or any situation where
pupils are fully dilated). Because of the distance
dominance of the central lens, minimal reduction in
light occurs in small pupil situations.2
 Bilateral ReZoom Implantations: Personal Experience 143

Fig. 1: ReZoom optical light distribution. The central portion of the optic is for distance vision.
The second zone is for near vision. The transition zones allow for intermediate light distribution also

The near dominant zones of this lens were
designed to offer +3.5D near add power at the IOL
plane, which is significantly greater than the 2 D
needed for most near tasks.
The rounded anterior edge (AMO calls it the
OptiEdge) reduces internal reflections. The OptiEdge
is basically three components—a rounded anterior
edge to reduce internal reflections, a sloping side edge
to minimize edge glare, and a square posterior edge
that helps keep 360º capsule contact to reduce
posterior capsular opacity. This type of edge was
found to reduce reflected images to about 1/3 of the
intensity of reflection in entirely square edge designs.3
With any multifocal IOL, centration in the bag is
critically important. The ReZoom is a 6 mm optic,
13 mm total diameter IOL. The lens is a 3-piece
design, with PMMA capsule fit haptics. In some
patients, intraoperative compromises in the capsular
bag structure may not allow the placement of a one-
piece multifocal IOL. The 3-piece design of the
ReZoom is more forgiving if the capsulorhexis is not
ideal, or even if it needs to be placed in the ciliary
sulcus, typically with capture of the optic in the
anterior capsular opening.
All of the improvements in the design from the
Array to the ReZoom have been aimed at optic zone
size and light direction that resulted in reduced halo
and glare, improved range of vision and visual
quality.
Our Results with the ReZoom Bilaterally
We analyzed our results retrospectively of
32 patients (64 eyes) who had bilateral ReZoom
implantation. The average age of the patients was
60.1 years; 24 were female.
Recovery of vision was rapid, and at the 1-month
postoperative visit, 47 of 59 (79.7%) eyes with data
had 20/30 or better vision in the distance without
correction. Near vision ranged from J1 to J7. No
patient had 1-month uncorrected vision worse than
20/50 or near vision without correction of worse
than J7. Typically near vision improves over time,
and some eyes will need laser vision correction
enhancement of residual refractive error.
At the 3-month follow-up all patients had data
available. Twenty-eight of 32 (87.5%) patients had
bilateral uncorrected distance vision of 20/30 or
144 Multifocal IOLs
better. Twenty-seven of 32 (84.4%) of patients had
bilateral uncorrected near vision of J3 or better
(Figs 2 to 4). Twenty-two patients (68.8%) had
UCVA distance of 20/25 or better and J3 or better
near vision.
Yag capsulotomy was performed in 13 eyes, two
eyes had LASIK, two eyes underwent IOL exchange
and one eye had phototherapeutic keratectomy (PTK)
for anterior basement membrane dystrophy with
irregular astigmatism. The IOL exchanges were in the
Fig. 2: Minnesota Eye Consultants results with bilateral
ReZoom showing bilateral uncorrected distance visual acuity
at 3 months postoperatively
Fig. 3: Minnesota Eye Consultants results with bilateral
ReZoom showing bilateral uncorrected near visual acuity at 3
months postoperatively
Fig. 4: Minnesota Eye Consultants results with bilateral
ReZoom showing bilateral uncorrected acuity for distance and
near
same patient, who initially complained of poor near
vision and difficulty reading and driving. Lens
exchange occurred 8-9 months after initial surgery.
By the 3-month follow-up, however, this patient was
20/25 and J2 in one eye and 20/30 and J1 in the
contralateral eye.
The postoperative vision in the patient who
underwent PTK was 20/20 and near vision was J1.
The eyes that underwent LASIK were 20/20 and J2
and 20/15 and J3.
One myopic cataract patient did have a retinal
detachment and one hypertensive patient with a
history of myocardial infarction had a branch retinal
artery occlusion.
What Others have Found in
Bilateral Implantation
Chiam and co-authors reported 20/32 or better
distance vision in all patients with bilateral ReZoom
implantation. Mean near visual acuity was J 2.34.
Mean intermediate visual acuity was 20/34 in the
ReZoom group.4
Another study by Tyson showed that 93% of
patients implanted bilaterally with the ReZoom lens
were able to achieve 20/25 or better uncorrected
distance vision5 (Fig. 5).
Dr Tyson also found that in his real-world
experience, a greater percent of patients achieved
 Bilateral ReZoom Implantations: Personal Experience
Fig. 5: Bilateral ReZoom results for distance vision in a group
of normal eyes from Farrell C. Tyson, M.D. Data Courtesy of
Farrell C. Tyson, MD
excellent near vision than in the original clinical study
used for FDA approval (Fig. 6).
Tyson also found the bilateral patients do have
improved vision at all distances after the second lens
is implanted which we have found as well. At our
practice, we spend a significant amount of time
discussing with the patient that monocular results
may not be as impressive as they had hoped for, but
with a little patience their binocular results after the
second lens implantation will be much better.
Akaishi reported similar results to the other
studies in a larger series of 240 eyes. He noted most
Fig. 6: Bilateral ReZoom results for near vision comparing
Dr. Tyson results with the FDA product labeling for ReZoom.
Data Courtesy of Farrell C Tyson, MD
145
patients had good distance and intermediate vision,
yet some noted near vision problems with occasional
spectacle use.6
It is my belief, and my personal experiences have
been similar those of Akaishi and Tyson, that
refractive multifocal lenses such as the ReZoom
depend on a 3 to 4 mm pupil diameters before patients
will achieve what they consider good near vision.
Pupil diameters reduce with age as well, so surgeons
must keep in mind how a pupil behaves at time of
surgery may be different than how that same pupil
will behave in 10 or 15 years. By implanting the
dominant eye first, patients get rapid information on
how they are going to do with a multifocal lens, and
then the surgeon may alter the power or style of the
non-dominant eye’s IOL if needed.
Custom Matching IOLs for Patients
based on Patient Feedback
Based on my successful results in most patients with
bilateral ReZoom implantation, our current strategy
for multifocal IOLs is to start with the idea that likely
we will end up with bilateral refractive multifocal
IOLs. We first implant the ReZoom IOL in the
dominant eye, or the eye with the worst cataract first.
We do everything we can to maximize visual recovery
speed so that at 1 to 2 weeks postoperatively we can
best assess the success in the first eye.
Items that maximize speed of recovery include
medications directed at reducing the impact and
frequency of cystoid macular edema such as topical
ketorolac (Acular LS, Allergan, Irvine, CA) pre- and
postoperatively. Aggressive identification of dry eye
disease preoperatively and management of this with
lid hygiene, artificial tears and cyclosporine
preoperatively and postoperatively also aids in visual
recovery. Cool phacoemulsification techniques with
pulsed phaco such as WhiteStar (AMO) are helpful
to reduce corneal edema postoperatively.
At the 1 to 2 week visit if the patient is achieving
acceptable uncorrected distance and near vision, then
in the second eye (usually the non-dominant) we
implant a ReZoom IOL with a distance target again,
as we did in the first dominant eye. If we have
achieved emmetropia, but the patient is not satisfied
with the near vision, then the second eye can be
targeted for about -0.5 D of myopia, or a diffractive
146 Multifocal IOLs
IOL could be used in the second eye (such as the
ReStor IOL (Alcon, Fort Worth, Texas) or the Tecnis
Multifocal IOL (AMO)). Unfortunately, the Tecnis
Multifocal IOL is not yet available in the United States.
If the patient has residual sphere or cylinder in the
first eye that is causing the lack of satisfaction with
distance or near vision, we typically implant the
second eye with the ReZoom IOL, and then at 3-6
months postoperatively perform laser vision
correction for residual sphere and cylinder.
A key parameter to the success of bilateral
implantation will be patient selection. If the patient’s
life revolves around intermediate vision, this will
typically convince me to opt for bilateral ReZoom
implantation. We initially aim for plano in the first
eye, but when forced to choose between going a
little minus or a little plus, implanting the ReZoom
with a little minus is preferable.
We prefer bilateral implantation over mixing the
implants if possible as this may improve the ability
of the patient to adapt to the glare and halo and it
avoids the phenomenon of the patient covering each
eye and comparing the IOLs. Still in some patients,
they are better served by a different IOL in each
eye to take advantage of the different benefits of a
diffractive and refractive IOL. Theoretically, the idea
behind mixing presbyopia-correcting IOLs is that the
non-dominant or second eye implanted will
complement the dominant eye’s lens. As Solomon
noted, however, in clinical practice the vast majority
of patients do not require this approach as
demonstrated by the FDA and postmarketing
studies of the three presbyopia-correcting lenses.7
In patients that are very demanding of their near
vision, or with small pupils, a refractive IOL in the
dominant eye and a diffractive IOL in the non-
dominant eye may work better. The ability to change
to a different lens for the second eye allows the
surgeon to assess the patient satisfaction with the
first implant and then adjust the second implant
based on the patient feedback.
During the period between the two eyes, the
patient should expect difficulty with any pre-existing
refractive error and the imbalance between the eyes.
Also they should be watching for situations where
they do not have adequate distance, intermediate,
or near vision, so that they can discuss this with the
surgeon at the visit where they will be deciding what
implant to use in the second eye.
About 20% of patients will initially notice signifi-
cant glare and halos, and as they are prepared for
this side effect of multifocality, it’s rarely a long-
term problem. As they begin to neuroadapt, the glare
and halos improve.
Most patients will adapt to the implants within a
few weeks after the second eye is done, yet there is
continued neuroadaptation even a year after the
surgery. It is uncommon to explant ReZoom IOLs
because of glare or halos in patients who did not have
successful neuroadaptation.
Multifocal IOLs are an excellent option for
patients who desire a reduction of dependence on
glasses after IOL surgery. Careful patient selection
will usually allow a satisfactory patient outcome.
Future advances in lens designs with an increased
range of focus and a reduction in visual side effects
will allow for implantation of these lenses in a
broader group of patients.
REFERENCES
1. Leyland M, Pringle E. Multifocal versus monofocal
intraocular lenses after cataract extraction. Cochrane
Database Syst Rev 2006;4:CD003169.
2. Artigas, JM, Menezo, JL, Peris C, et al. Image quality
with multifocal intraocular lenses and the effect of pupil
size: comparison of refractive and hybrid refractive-
diffractive designs. J Cataract Refract Surg 2007;
33(12):2111-7.
3. Franchini A, Gallarati BZ, Vaccari E. Computerized
analysis of the effects of intraocular lens edge design on
the quality of vision in pseudophakic patients. J Cataract
Refract Surg 2003;29:342-7.
4. Chiam PJ, Chan JH, Haider SI, et al. Functional vision
with bilateral ReZoom and ReSTOR intraocular lenses
6 months after cataract surgery. J Cataract Refract Surg
2007;33(12):2057-61.
5. Tyson FC. Bilateral IOLs achieve surprising results.
Refractive Surgery Quarterly 2006;5(1):1-6.
6. Akaishi L, Fabri PP. PC IOLs mix and match
technologies: Brazilian experience. Paper presented at:
The World Ophthalmology Congress; 2006; Sao Paulo,
Brazil.
7. Solomon K. Why not to mix and match IOLs. Cataract
Refract Surg Today 2006;99-102.

18
Multifocal IOLs in Children
Cataract surgery in children is the most satisfying
surgery in Ophthalmology. You have the ability to
give long-term benefits which often will exceed even
the life of the surgeon. However, it needs a regular
follow up for the rest of the patient’s life if good results
are to be maintained.
Though it has changed considerably in last
35 years, it has now become very successful due to
early intervention and immediate optical correction
and the availability of superlative multifocal
implants.
Though intraocular implants in children are a well
established entity, it required the efforts of
McClatchey and Hofmesiter (1997, 1998, 2000, 2005)
who demonstrated that after the age of 6 months, the
intraocular power calculation follows a virtual linear
logarithmic pattern thus proving that the refractive
status of the eye can be predicted in a high level of
accuracy.
Coupled with the ability to achieve this level of
accuracy are the advent of the newer, more
sophisticated, computer controlled cataract removal
devices and the availability of nonultrasound units
like the AquaLase (Alcon) which permit a completely
safe surgery with a virtual zero risk potential. Long-
term assessment of posterior capsulorrhexis and core
vitrectomy has shown the inherent safety of the
procedures.
Until the availability of high quality multifocal
IOLs one had to be content with inserting monofocal
implants in children. The most popular being the
Alcon single piece AcrySof IOL. The material, thanks
Multifocal IOLs in Children 147
Keiki R Mehta, Cyres K Mehta, Zenobia K Mehta
to its bio adhesiveabilty and the restriction of
capsular growth due to the square edged design
made it a very popular IOL in infants and children
Though the monofocal IOL created no problems,
it was an obvious fact that the child had, for practical
purposes had no functional near vision. For children,
their proximal horizon accounts for more than 80%
of their daily activities, it became extremely
problematical. There is nothing sadder than to see a
little child with reading glasses or wearing bifocal
trying to move his head to focus. It placed a great
deal of restrictions on the daily activities and in many
ways was a psychological barrier leading to reclusive
children as the grew up. A daily reminder to both the
children and the parents that the child was a visually
deficient.
Stein 2004, critically analyzed and brought out
three salient factors which need consideration
(a) Critical period of visual maturation completes in
3 to 4 months period. (b) Up to the age of 8 months
the visual apparatus goes on developing at a very
rapid rate, and perhaps the most important (c) The
ability to see near and distance important for the
child to be able to develop depth perception and
enhance visual development.
Jacobi PC; Dietlein TS2001 from the University
of Cologne, Cologne, Germany. Evaluated implan-
tation of a zonal-progressive multifocal intraocular
lens (IOL) in children. Thirty-five eyes of 26 pediatric
patients aged 2 to 14 years with multifocal IOL
implantation at one institution with more than 1 year
of follow-up using a multifocal IOL (Array SA40-N;
148 Multifocal IOLs
Allergan, Irvine, CA) implantation in all eyes. Their
results were very encouraging. Twenty-six patients
(35 eyes) had an average follow-up of 27.4 +/- 12.7
months (range, 12-58 months). At last follow-up,
best-corrected distance visual acuity improved
significantly (P = 0.001), 71% of eyes with a visual
acuity of 20/40 or better and 31% of eyes with a
visual acuity of 20/25 or better. In the 9 bilateral
cases, spectacle dependency was moderate, with
only 2 children (22%) reporting the permanent use
of an additional near correction. The remaining
children were either using distance-correction only
(4 patients; 44%) or no glasses at all (3 patients; 33%).
Stereopsis also improved significantly after
multifocal IOL implantation (P = 0.01). They conclu-
ded that Multifocal IOL implantation is a viable
alternative to monofocal pseudophakia in this age
group.
With all the above factors described, a trend of
thinking about the use of multifocal implants in
infants and children as a routine was taken up. In the
earlier days, the Silicone Array (Allergan) had the
problems of decentrage, typical to silicone based
IOL’s. The newer hydrophobic acrylic material, the
Allergen ReZoom multizone IOL and the Alcon
ReStor, and the Tecnis Diffractive multifocal seemed
to be the newest additional to the armamentarium
and fortunately fixate very well.
The Mehta International Eye Institute runs a well
established contact lens clinic with a good
Optometrist (ZKM), however for many years, fitting
contact lenses in small children has been a labor of
love. Unfortunately the success rates with contact
lenses even in the best of hands, in small infants and
children, have been poor. Implants were the obvious
answer and were implanted in all cases unless
contraindicated with latent nystagmus, micro-
phthalmos, uncontrolled glaucoma. Though
originally monofocal lenses were fitted in children we
used to give bifocal spectacle lenses. However we
soon had to discontinue this practice since once other
children made fun of the child it would never wear
spectacle, and tended to make a child insecure and
unhappy. It has been a practice for many years at the
Institute that following implantation that the children
were always fitted with varifocal glasses, with no
segment visible. Children adapt to varifocality very
easily, there never being the problems of adaptation.
Even a 3 year old once he perceives the obvious
benefits will wear his glasses. Not having separate
reading glasses or having glasses with a bifocal
segment obvious, makes wearing of the glasses easier
with no social stigma attached to them.
Considering how easily children accept
varifocality, and with the encouraging results in the
ophthalmic literature, we had decided onto the
concept of multifocal IOL for all children over the age
of 2 years. An additional small power could be worn
over as single vision glasses, in those whom we had
calculated as an excess, which would over time, with
the myopic shift achieve Emmetropia in adulthood.
Naturally as the reading addition in the implants
was a 3.5 to 4.00 D, it sufficed for all.
MULTIFOCAL IOLs IN
CHILDREN (Fig. 1A and B)
We commenced multifocal IOL’s in 2002 February.
The one good IOL available was the Allergan Array
IOL. A year later came the Preziol. IOL, an acrylic
foldable IOL very economical, which was a three
zone IOL.made by the CareGroup, at Baroda, India.
The results were immediate. The children were very
contented and there was no immediate problem. We
used a good number (74) of Array IOL The long-
term problem of the Array was the tendency to shift
out from the center (decenter) due to eccentric bag
contraction typical of silicone IOLs.
In 2005 came the newer ReZoom, 5 zone multifocal
and in early 2006 cane the ReStor IOL made by Alcon,
the first 2 infants were implanted with the ReStor in
India in March and June of 2006. Implantation of a
zonal-progressive multifocal IOL’s in pediatric
cataract (Figs 1A and B) patients provides a high
level of distance-corrected far, intermediate and near
vision, reduced spectacle dependence and improved
binocular vision.
Again the acceptability was very good. The
ReZoom and the ReStor gave good intermediate
vision which was very gratifying.
With the advent of the new Multifocal IOL from
Rayner, we have virtually shifted to it and have
achieved good results. The biggest advantage of the
Rayner multifocal is, for India, the cost, almost a
quarter of the cost of other implants.

Fig. 1A: Nine year child with bilateral cataracts
Fig. 1B: Congenital cataract
At present we have restricted ourselves to only
acrylic materials as silicone materials just do not have
the level of centrage required which should be
mandatory in children. We use the ReZoom and the
ReStor for affording cases, while the Rayner
multifocal and the Preziol has been kept for those
who cannot afford the otherwise, extremely (for
India) costly IOL’s. Interestingly, though the Preziol
is a 3 stage IOL, still some intermediate vision is
existent too and the patients even with the more
economical implant are quite satisfied.
Multifocal IOLs in Children 149
The Acrysof ReStor ® Intraocular Lens has a
patented optic design using apodization, diffraction
and refraction technologies. Apodization is a gradual
reduction or blending of the diffractive step heights.
The apodized diffractive optic design gives it the
ability to focus light correctly on the retina for images
at various distances without mechanical movement
of the lens. Apodization optimally manages light
energy delivered to the retina because it distributes
the appropriate amount of light to near and distant
focal points, regardless of the lighting situation.
Apodization based diffractive optics are designed to
improve image quality while minimizing visual
disturbances. The result is an increased range of
quality vision that delivers a high level of spectacle
freedom.
The ReZoom ™Multifocal Lens an hydrophilic
acrylic implant has a patented lens design called
Balanced View Optics™ Technology. This lens design
creates multiple focal points so patients can see well
at a variety of distances, be it near, mid-distance, or
far.
The ReZoom™ Multifocal Lens has carefully
proportioned visual zones that provide it with the
ability to provide patients with vision at varying
distances.
Each ReZoom™ Multifocal Lens is divided into
five different zones with each zone designed for
different light and focal distances.
Unlike other earlier multifocal lens designs,
(Array) the ReZoom™ Multifocal Lens has
proportioned the size of its zones to provide for good
vision in a range of light conditions.
Since the last 6 months we now have availability
of the Rayner multifocal IOL which again is a The
Rayner M-flex™ (630 F) hydrophilic acrylic injectable
IOL which provides a degree of pseudoaccommo-
dation, lessening the need for additional correction
by spectacles or contact lenses.
The Rayner M-flex™ Multifocal IOL is based on
a multi-zoned aspheric optic technology with either
4 or 5 annular zones (depending on IOL base power)
providing 3.0 diopters of additional refractive power
selected for optimum performance with reduced
incidence of halo or glare (equivalent to 2.25 diopters
at the spectacle plane).
150 Multifocal IOLs
PERIOPERATIVE ROUTINE AND SELECTION OF
ANESTHETIC AGENTS
We always try to keep the child and the adult
caregiver together preoperative and postoperative
the surgery as this is a very trying time for both.
Too early a separation leads to a very unhappy,
distraught mother and a weeping completely non-
cooperative child.
We permit children to receive clear liquids 3 hr
before surgery without increasing the risk of
aspiration.! Adequate preoperative hydration
diminishes the incidence of intraoperative
hypoglycemia and hypovolemia and postoperative
nausea and vomiting.
Though many institutions routinely use
premedication for young children (between 18
months and 5 years of age) before ophthalmic
procedures we have nether never found it useful,
nor necessary.
Both inhalational and intravenous general
anesthetic techniques have been used successfully for
pediatric cataract surgery. We prefer, anesthesia in
young children undergoing cataract surgery with an
inhalational agent. Isoflurane has widely replaced
halothane as the induction agent of choice in children.
It possesses a less offensive odor than other volatile
agents, is less stimulating to the airway, and lacks
the arrhythmogenic properties of halothane.
Nitrous oxide, traditionally used with volatile
anesthetics, may increase postoperative nausea and
vomiting. Though the relationship between nausea/
vomiting and nitrous oxide remains controversial it
occurs too often to be disregarded.
Propofol is the intravenous induction agent of
choice for cataract surgery in older pediatric patients
and those with preoperative intravenous access.
Propofol is an isopropyl phenol that has a rapid onset
and offset of action. It is used for the induction and
maintenance of anesthesia or sedation. Intravenous
injection of a therapeutic dose of propofol produces
hypnosis rapidly with minimal excitation. Propofol
is also believed to have antiemetic properties. It
effectively produces hypnosis of short duration with
minimal “hangover.” As a routine we usually
combine it with ketamine hydrochloride, a
dissociative anesthetic that can be used for the
induction and maintenance of anesthesia. However
ketamine hydrochloride does causes an increase in
IOP, which should be kept in mind when following
patients with glaucoma.
During anesthesia, even in patients whose IOP is
usually normal, an increase in IOP can produce often
irreversible catastrophic effects. This may lead to
prolapse of the iris and lens and loss of vitreous.
Therefore, proper control of IOP is critical. We usually
supplement the anesthesia with a1.5 cc sub-tenon
block, given via a blunt rounded 24 gauge cannula,
and let the eye soften for 3 minutes which obviates
much of the risk of giving extra inhalation or injectable
anesthesia.
The anesthesiologist can use the Bell’s pheno-
menon is a useful indicator at any time during
anesthesia when the patient’s depth of anesthesia has
changed. It manifests as upward (or sometime
downward) movement of the eye. It is usually a sign
of being light, although the patient is not awake. It is
an indicator that the anesthesiologist should be pre-
pared to “deepen” the anesthesia to facilitate
surgery.
OCULOCARDIAC REFLEX
The oculocardiac reflex is stimulated by pressure on
the globe and/or by traction on the extraocular
muscles, the conjunctiva, or the orbital structures. The
afferent limb is trigeminal and the efferent limb is
vagal. Although the oculocardiac reflex is commonly
associated with bradycardia, virtually any
dysrhythmia, including ventricular tachycardia and
asystole, may be seen.3.4
It must be remembered that Children have
increased vagal tone and, therefore, are more likely
to present with the reflex. If a dysrhythmia appears,
the surgeon to cease the manipulation and check that
the depth of anesthesia and ventilatory status are
adequate. Usually, the heart rate and rhythm return
to baseline within 20 sec. If the reflex becomes a
problem, atropine should be given intravenously.
SURGICAL TECHNIQUE (Fig. 2)
A well made surgical tunnel is mandatory for babies
and young children. It is important that the tunnels
be made well. The first step is to make two 0.8 mm
tunnels at 9:00 o’clock and 2:00 o’clock. The tunnels
 Multifocal IOLs in Children 151

Fig. 2: Side port openings made with a 1.2 mm diamond knife, 3.00 mm diamond knife opens the main opening.
Note wide tunnel to permit, Easy closure

are made by applanating the scleral surface so that
the tunnels are longer than they are broad. The next
step is to fill the eye with an OVD (Ophthalmic Visco
surgical device). The best in the opinion of the authors
is Viscoat by Alcon. The next best is Healon 5. The
most economical is methylcellulose which unfortu-
nately runs out freely. If Methylcellulose is to be
utilized it should be frozen (kept under the freezer).
Methylcellulose increases its viscosity by a factor of 3
if frozen and does not run out at all. However once it
warms up it runs again freely.
The next step is to carefully ‘construct’ the corneal
incision. Refill OVD. Once again taking a 2.8 mm
diamond blade (ideal for children) applanated it to
the sclera and then advance. Only enter the tunnel
after the length is more than the breadth. Be careful
when removing the blade not to incise the walls of
the tunnel.
Rhexis (Fig. 3) in young children is best
commenced with a sharp bent 27 G needle as the
capsule is tough and does not give way easily and
then continue the rhexis with a capsule forceps
refilling the OVD at regular intervals. Do remember
in children that the tendency is for the rhexis to
increase. So plan for a 5 mm rhexis and it invariably
becomes bigger. If the eye is soft, after a block, rhexis
is far easier. To do a rhexis in a tight eye is foolish
as it will run away.
Hydrodissection under the rhexis is done with a
blunt tipped side ported 24 G cannula. That way
accidental injury to the capsule is avoided if the
chamber suddenly shallows. The Hydrodissection is
started at the 7.00 o’clock position and fluid injected
slowly in all the clock hours. Usually the nucleus
will tumble out if the cataract is soft.
The authors use the Alcon AquaLase (Figs 4A
and B) which uses bursts of warmed water as a
routine in children. It has a polymer blunt tip which
protects the capsule. It is essential not to increase
the suction too much. Usually all the cortex can be

Fig. 3: Rhexis carried out with a forceps, hydrodissection in the periphery of the lens
152 Multifocal IOLs

Fig. 4A: Aqualase in action, notice fluid burst from tip

Fig. 4B: Aqualase placed peripherally allows circumferential aspiration of the nuclear material

easily removed with the AquaLase but if any is left
behind it can be easily removed with an I/A bimanual
system (Fig. 5).
AquaLase polishing if the capsule is essential. It
leaves a very clean capsule. If not available than
manual polishing of the capsule is compulsory.
Refill the chamber with the OVD of your choice
and inject in the IOL.
The Intraocular implant is placed in its folder
being careful to be sure that it is properly sited and
then injected into the eye using the proprietary
injector. The 2.8 mm incision is ore than adequate
for both the ReZoom and the ReStor Iol and even
the Preziol which has its own disposable injector.
The pupil is narrowed with a miotic (Intracameral
pilocarpine 1% with no preservative works well).
The pupil must be brought down to less than 4 mm
prior leaving the case as in a child any sudden
pressure will lead to the Iol being captured in the
iris.
Up to the age of 4 years we do a posterior rhexis,
but that to only after implanting the IOL, after
ascertaining that the pressure and the anesthesia is
very stable. The PCCC is followed by a short core
anterior vitrectomy. The vitrectomy is an essential
part of the procedure. Reports mention almost 63%
of PCCC close by secondary membrane formation if
core vitrectomy is not carried out. Usually following

Fig. 5: Final cortical clean up with low powered aqualase,
Irrigation aspiration with a bimanual hand pieces completes the procedure
the AquaLase polishing the capsules are very clear.
We prefer to delay doing the Posterior capsulotomy
if the conditions are not ideal and prefer to enter
via after 3 months when the IOL has had a good
chance to stabilize.
After the age of 4 we prefer to simply do a YAG
capsulotomy as a more stable procedure.
The chamber following surgery must reform with
saline, and stay formed on the table. If the chamber
immediately flattens, it is prudent to take a single
10/0 Vicryl buried stitch at the site of the corneal
incision.
Imperative
An exceptional cleaning of the anterior chamber
should be done. Meticulous removal of even slight
traces of blood from anterior chamber at the end of
surgery is must. Epithelial cell metaplasic activities
uses the intact anterior vitreous face, as well as
surface of IOL as scaffolding, also RBCs are source
of fibrosis.
Post Operative treatment is fairly simple. We do
not permit the mother to handle an infant or even a
small child’s eyes under any circumstance. The
mother is taught to place the drops in the inner corner
of the eye and simply pat the child on the abdomen
gently and wait. The moment the eye opens the
drops go in. The child lids are very tight and very
closely apposed to the eye. Any forcible effort only
leads to the drops being literally “wipered” off.
Previously we used to use Tobramycine , now
replaced by Vigamox (Alcon) Moxifloxacin) eye
drops T.I.D with Prednisolone eye drops t.i.d.
Multifocal IOLs in Children 153
It is coupled with oral steroids. We are very happy
using Oral drops of Betamethasone, 10 drops, b.i.d
for children under 3 years of age, t.i.d for up to 5 years
of age and q.i.d for over 7 years, to be used for a
month. This usually takes care of any inflammation.
We strongly recommend against using mydriatics,
as children being inveterate rubbers will often
precipitate with an iris capture. We routinely use a
drop of 1% pilocarpine once a day for a month. In
this regime, we never get lens capture, get perfectly
centered pupils and do not have any inflammation.
Posterior Rhexis and Vitrectomy
There have been many publications since the time
that Gimbel taught that a PCCC with an optic capture
is the way to go. If the eye is soft, and the child is
under GA with positive pressure insufflations, doing
a PCCC is easy. However if the anesthesia is not
perfect and the eye is a bit tight, an attempt at PCCC
often leads to a tear with vitreous in the A/C which
means that the stability of the IOL is immediately at
risk. We do not like doing a core vitrectomy after
the teaching of Jan Worst who in his recent book on
‘Cisternal Anatomy of the Vitreous’ in 1995 showed
that Cisternal abrogation was the cause of many of
the postoperative problems related to the macula.
Statistics
We have done, 212 eyes, 88 are bilateral, 36 are
unilateral of over the last 51/2 years starting from
February of 2002. The results have been very
gratifying. The maximum multifocal IOLs(Table 1)
have been from the Allergan Array with the next
154 Multifocal IOLs

Table 1: Multifocal IOLs Implanted Table 4: Types of IOL

Unilateral or bilateral Type of IOL implanted Manufacturer No %

Unilateral % Bilateral % Total Children Preziol (Care Group) 40 18.8

M Flex (Rayner) 32 15.2
36 29.3 88 70.7 124
Array (Allergan) 74 34.9
Total eyes 36 + 176 (88*2) = 212 eyes ReZoom (AMO) 52 24.5
ReStor (Alcon) 14 6.6

Table 2 : Age at Implantation of child

CONCLUSION
Age at Implantation No % It would seem from a 41/2 year study which we are
still evaluating that a primary Multifocal IOL is the
<2 yrs 23 10.8
2-3 years 35 16.5
way to go in infants and your pediatric cataracts.
4-6 years 51 24.2 Regrettably Children are brought too late,
7-9 years 48 22.6 parents and doctors are not aware of cataract. There
10-12 years 55 25.9 are still too many opinions regarding whether an
IOL should be placed in a small child, let alone a
highest, the ReZoom. Since the last 6 months we are multifocal IOL, and invariably the parents are
putting in many more M Flex (Rayner) with good skeptical about surgery.
results. Too many opinions, wastes precious time. Equally
The visual results have been excellent in the unfortunate is the concept in India of waiting till the
bilateral group with 85% of them achieving 6/12 or cataract is mature to the level that one cannot see one’s
better with the maximum correction and N8 easily. finger in adults. It is this concept which they apply to
The unilateral group consisted of some who are the child not realizing that it will, in the long run
bilateral but have not yet had the surgery done in affect the rehabilitation of the child.
the other eye. Again the results are excellent but the It is also important to calculate the power as
unilateral cataract with no or negligible cataract in precisely as possible and if there is residual ametropia
the second eye have all achieved a maximum result correct with glasses or contact lenses as may prove
of 6/18 , 4 of whom are 6/24. which is reasonable necessary and consider the option of doing an
considering that unilateral cataracts invariably do not Excimer laser at a later date after the child grows up.
do as well due to a latent amblyopia? Interestingly, The aim is to get as perfect a visual result as
the near vision is N8 which shows the near vision possible and to make the child achieve good vision
seems to be better than the distance in these unilateral with no additional visual props which would affect
cataracts. Nine eyes had to be re-operated to center the child’s ability to compete in the world of today.
the IOL.
REFERENCES
Table 3: Complications n = 212 1. McClatchy SK. Eyed all a comparison of the rate of
refractive growth in pediatric aphakic and pseudophakic
Complication No % eyes. Ophthalmology 2000;107:118-22.
2. Jacobi PC, Dietlein TS, Jacobi FK. Scleral fixation of
Corneal abrasion 03 1.4 secondary foldable multifocal intraocular lens implants
Shallow A/C 11 5.1 in children and young adults. Ophthalmology
Iritis Mild 12 5.6 2002;109:2315-24.
Iritis severe 03 1.4 3. Ozmen AT, Dogru M, Erturk H, Ozcetin H. Transsclerally
Raised IOP.Temp 15 7.1 fixated intraocular lenses in children. Ophthalmic Surg
Raised IOP .needed surgery 02 0.9 Lasers 2002;33:394-99.
Hyphema 07 3.3 4. Ahmadieh H, Javadi MA. Intraocular lens implantation
IOL decentrage needs surg. 09 4.2 in children. Curr Opin Ophthalmol 2001;12:30-34.

5. Peterseim MW, Wilson ME. Bilateral intraocular lens
implantation in the pediatric population. Ophthalmology
2000;10:1261.
6. Pavlovic S. Cataract surgery in children. Med Pregl
2000;53:257-61.
7. Moore BD. Pediatric aphakic contact lens wear: rates of
successful wear. J Pediatr Ophthalmol Strabismus
1993;30:253-58.
8. Speeg-Schatz C, Flament J, Weissrock M. Congenital
cataract extraction with primary aphakia and secondary
intraocular lens implantation in the ciliary sulcus. J
Cataract Refract Surg 2005;31:750-56.
9. Menezo JL, Taboada J. Assessment of intraocular lens
implantation in children. J Am Intraocul Implant Soc
1982;8:131-35.
Multifocal IOLs in Children 155
10. Blaylock JF, Si Z, Vickers C. Visual and refractive status
at different focal distances after implantation of the
ReSTOR multifocal intraocular lens. J Cataract Refract
Surg 2006;32:1464-73.
11. Bellucci R. Multifocal intraocular lenses. Curr Opin
Ophthalmol 2005;16:33-37.
12. Jacobi PC, Dietlein TS. Konen WMultifocal intraocular
lens implantation in pediatric cataract surgery.
Ophthalmology 2001;108:1375-80 (ISSN: 0161-6420).
13. Jacobi PC, Dietlein TS, Lueke C, Jacobi FK. Multifocal
intraocular lens implantation in patients with traumatic
cataract. Ophthalmology 2003;110:531-38.
14. Chiam PJ, Chan JH, Aggarwal RK, Kasaby SReSTOR
intraocular lens implantation in cataract surgery: quality
of vision. J Cataract Refract Surg 2006;32:1459-63.
 19
How to Proceed with
Multifocals in Children?

Roche Olivier

INTRODUCTION It allows the best optical rehabilitation compared

with contact lenses or glasses.4-6 Even, pseudophakic
Early surgical management of visual impairment of
glaucoma7 is less common than aphakic glaucoma.8
phakic origins in children is necessary to give a good
Many hypotheses explained the development of
result. Surgery must be performed in cases with
glaucoma in aphakia by the pupillary block with
dense congenital cataracts before the development
posterior synechiae, trabeculum block by the
of nystagmus and irreversible amblyopia. Factors
vitreous, chronic intraocular inflammation or
as the timing for surgery, the type of surgical techni-
regression of the Soemmering ring. Finally, the
ques, the optical correction of aphakia or the calcula-
separation between anterior and posterior seg-
tion of the lens power are actually resolved. What-
ments seems to be decreasing the incidence of
ever the causes of the trouble vision like cataract or
glaucoma.7,9
ectopia, choice of intraocular lens type, choosing the
Surgical removal of ocular lens induces iatrogenic
age for intervention, making posterior capsulorhexis
presbyopia. Vision in the intermediate distance is
with anterior vitrectomy are still controversial.1
not allowed with unifocal intraocular lens implan-
The refractive outcome following the IOL
tation. Except in case of refractive difference
(intraocular lens) implantation depends on the age
between the two eyes, optical correction is made by
of the child. Surgery in early infancy is associated
progressive or bifocal glasses. In these cases,
with high risks of complications and refractive error
sensitive and oculomotor affections can alter the
because of uncertain infantile ocular growth. Doubts
binocular vision and could even give amblyopia.
concerning the adequate optical rehabilitation by
These complications are less seen with multifocal
multifocal intraocular lens in children are still there.
intraocular implantation.
However, rehabilitation and management of
Halos are both observed with unifocal and
pseudophakic amblyopia by active vision therapy in
multifocal lens. New multifocal lens have best
the management of these pseudophakic cases is
refractory results allowing children to adapt their
possible and efficient. We must not confuse the goal
vision better.
of optical rehabilitation in children with the
refractive surgery proposed for adults. Choice of the Lens
Refractive results for long distance vision are the
GENERAL POINTS: INTRAOCULAR LENS
same between unifocal and multifocal lens.10 Visual
IMPLANTATION IN CHILDREN
field is conserved. Sometimes, orthoptic tests show
The ocular development of children is not altered convergence dysfunction. With new optical concepts,
whatever the kind of intraocular lens implantation.2,3 the contrast vision not much altered and the

nocturnal vision is altered in less than 5% of cases.
Moreover, the ophthalmological examination for the
fundus and applying laser are easier in multifocal
than in unifocal lens.
Various kinds of multifocal lens exist: diffractive,
refractive or mixt. In all cases, it required a healthy
retina and a cortical image for good result.
Characteristics of implants influence the post-
operative visual acuity, the formation of secondary
cataract, the apparition of fibrosis and retraction of
the capsule.
All materials are used (acrylic hydrophobic,
monobloc or three-part PMMA, silicone, PMMA
untreated or treated surface (heparin, fluor) 11,12
except hydrophilic lens which is not recommended
because of its rate of opacification and its
intracapsular instability. The rigidity of the implants
is also important in infant because we foresee later
a strong capsular retraction. So acrylic hydrophobic
lens are recommended because of their rigidity and
injectability. The implant design also is important
for decreasing the cell proliferation. It is true that
lens must be in capsule or in sulcus and when the
capsule become retracted and fibrosed we can rotate
it easily with a small corneal incision using hooked
rotator to slip inside the sulcus. So the design of
three-part lens is preferable.13
Lens diameter must be at least of 6 mm with
a total diameter (including the haptics) that has
to be adapted to the age of the patient (10.5 mm till
18 months, 11 mm till 3 years and 12 mm till
8 years).11-14
For having a good postoperative result,
multifocal lens has to be intracapsularly centralized,
the pupil has to be moving freely and postoperative
follow-up has to be done by specialist ophthalmo-
logist.15,16 Even, if the pupil moving is a little bit
restricted or the lens is a little bit uncentralized, the
refractive result does not change too much.
ReZoom®, AMO Inc., seems to be the best choice
according to its characteristics.
When Can We Use Multifocal Lens?
In our experience, limits for intraocular implantation
are the same for unifocal and multifocal lens and
are not linked with the age of patients. Some
ophthalmologists, who referred to study on
How to Proceed with Multifocals in Children? 157
monkeys, think that management of amblyopia is
difficult with multifocal lens.17,18
We practiced more than 500 surgeries on infants
aged from months to 7 years. We start with
traumatic cataracts with a good reference of the
previous visual acuity before the accident that allows
us to have a good follow-up. When patients have a
traumatic cataract between 3 and 4 years, we notice
that they have a good result with management of
amblyopia. Even though it happened to have severe
amblyopia with strabismus, the management can
improve the condition even it takes a long time. So
there is no evidence that we can not treat amblyopia
in patients with multifocal lens. We have not to forget
that even sometimes with a severe congenital cataract
operating with unifocal does not treat amblyopia.
The axial length of the eye with the corneal
diameter rapidly increases in the first year (4-5 mm)
which is the rapid phase. The second phase is the
slower one till 3.5 years’ old when the eye reaches
its most size (Fig. 1).19,20
Fig. 1: Growth curve of the eye
All of that can make the calculation of the implant
more difficult. In some particular cases like
microphthalmia, it’s more difficult to calculate the
power of the implant because of unpredictable length
axial growth.21-24
How We Can Calculate the Power of the Implant?
The idea of implant calculation is to reach emmetropia
at the time of the eye growth stop. That prediction
could be sometimes inaccurate. Parents must be
informed about that. More over, the hypermetropia
158 Multifocal IOLs
postoperative (especially in young infants) is always
there which could be treated by glasses or contact
lenses. On those bases, the optical correction has to
consider the far distant vision. Multifocal parts in
the lens will make the refractive correction more
difficult than with unifocal. We have to consider that
the prescription of postoperative glasses is not a
failure of the management but it is a part of it.
Because the development of keratometry is
limited,25 we consider average corneal keratometry
of 46.15 D for congenital anomalies and 44.44 D for
other cases. Using table of calculation considering
age corrected factors is recommended to reach
emmetropia.12
Till now, average formula depending on SRK II
and Holladay is the most used considering 65% of
the power is given between 6 months and 1 year,
and a decreasing by 5% every year till a complete
emmetropia.26 Recently, average formula depending
on Hoffer Q and Holladay 2 are more adapted for
young axial length (< 22 mm).2,3 However, these
formulas’s can be used for calculating the power in
a given anatomical condition but not for growing
axial length. Moreover, axial length is probably
modified by intraocular implantation.2,12
Is it important to do Posterior Capsulorhexis with
Anterior Vitrectomy in Multifocal Implantation?
The lens develops from the ectoderm, and it grows
from the cells in the equatorial zone, which explain
the cell proliferation after lens implantation especially
Fig. 2: SA40N multifocal implant in place, edges of the
rhexis posterior and anterior (arrow)
in infants between 2 and 3 years’ old. Posterior
capsulorhexis has to be with anterior vitrectomy
because anterior hyaloids can give a support for the
equatorial cells (Fig. 2). It is true that the practice of
posterior capsulorhexis and anterior vitrectomy can
give decentralization of the lens,21 but it is better
than having a posterior capsule opacity which will
be difficult to manage in these young patients.
Secondary implantation
Secondary implantation is indicated when the ocular
growth is finished or when the contact lenses become
non-tolerated, or in bilateral cases when the glasses
become undesirable for a plastic reason. NB: make
sure that there is a good capsule remnant for
supporting the secondary implantation otherwise
using the sulcus. Even though we can fix it in the
sulcus with sutures on the pars plana or on the iris,
without any risk for the retina. In this case, anterior
vitrectomy is necessary as a complementary
procedure. Sometimes attachment of the iris to the
capsule remnant can interfere with iris fixation.
Advantages of secondary implantation are precise
refractive correction and less inflammatory response.
Contraindication
General disease like autoimmune with risk of
aggressive immune response, dermatosis like
ichthyosis or incontinentia pigmenti, disease linked
with NEMO genes are contraindicated because of
their association with optical cell deposit and
synechiae.
Severe ocular malformations like severe
microphthalmia or primary vitreous are contra-
indicated whatever the type of the lens. Anyway,
corneal changes (dystrophia, dermoid cyst,
dysgenesia) or some astigmatism make limitation
of using a multifocal implant. Also, multifocal
implantation is controversial in iris anomaly
(aniridia, Rieger syndrome, coloboma) or in retinal
anomaly (dystrophia, coloboma).
Finally, it is logic not to implant second eye with
multifocal lens when the first eye had been implanted
with unifocal.
Strabismus and nystagmus are not contraindi-
cated for primary or secondary implantation, even
though it can reduce the deviation.
 How to Proceed with Multifocals in Children? 159

Preoperative Points Capsular sac retraction with decentralizing the

lens is the most dangerous complication for the
Some points have to be respected before the surgery.
efficacy of the multifocality, which happened usually
Information has to be clear and honest to the parents.
at the second month (Fig. 3). Cell proliferation
They have to be reminded that the infant can wear
happened at the same time (Fig. 4).
glasses after the surgery; the intermediate vision will
be less satisfactory rather than the far and the near
vision, the near vision distance going to be more
nearer than the normal. They will need more strong
light than normal and seeing halos could be normal.
It need extensive follow-up.
It includes orthoptic exam, refraction under
cycloplegia, keratometry, slit-lamp examination,
ocular pressure, and measuring axial length,
calculation of the power lens. Complete ophthal-
mological examinations under general anesthesia are
essential before surgery.

Surgical Techniques
Under general anesthesia, using sclera-corneal
incision, a large continuous anterior capsulorhexis,
soft hydrodissection with phakoaspiration, posterior
Fig. 3: Array fibrosis and decentration age 2 months
capsulorhexis and anterior vitrectomy are needed.
Then lens injection with positioning haptics inside
the sac (or the sulcus if it is impossible). Suturing
the incision for good close is essential. Any surgical
complication contraindicates using multifocal lens.

Postoperative Follow-up
Intensive anti-inflammatory postoperative therapy
is important using corticoids with association of
antibiotic: corticoid instillation every hour the first
24 hours, then 8 times per day during 1 month,
general cortical therapy for 5 days with strong dose
(0.8 mg/kg/day).
Follow-up has to be next day, one week, 5 weeks
and then 4-6 months. Orthoptic exam and vision
acuity have to be done after the 5 weeks post-
operative, when the refractive correction considering
far vision is done. Automatic refractometry without Fig. 4: ReZoom secondary proliferations
on a multifocal implant
cycloplegia, measuring the far vision and the near
vision depending on pupillary size. Two results so
are taken with a difference of addition from 2.65 D
RESULTS
corresponding to the 3.5 D of implant addition.
Treatment of amblyopia is always considered with At the time, we are going to publish a prospective,
a long time putting in mind that the expected visual noncomparative, case series study that measuring
acuity after congenital cataract surgery is not visual results and the quality of life before and after
necessarily being 10/10. multifocal implantation (primary and secondary).
160 Multifocal IOLs
Selection of the patients was made between 2001
and 2005 at Necker Hospital-Enfants Malades, APHP,
René Descartes University, Paris 5, France.
Patients were divided in 3 groups: primary
implantation, secondary implantation and lens sclera
sutures in case of lens ectopia, with age of
implantation 2.5-16 years.
First Group: 125 eyes of 97 infants. Mean age:
5.1 years (range, 2.5-15.7 years). Bilateral cases:
28 and unilateral: 69, with average lens power: 23 ±
4.1 D (range, 14-30 D). Average duration of gaining
the best visual acuity was 9 ± 3.5 months. Before
surgery, refractive correction was – 2 (+ 2) 80° ± 1.8
(range, – 6 – + 7) for best far visual acuity 0.3 and
near visual acuity with correction 80% parinaud
5 (p5). It was p4 in 60%. With a 9 month follow-up,
refractive correction was – 1 (+ 1.5)95° with best
corrected far visual acuity at 0.7 (p < 0.05). Best
corrected near vision was p4 in 76% and p3 in 56%
(p < 0.05).
Second Group: 66 eyes of 41 infants. Mean age 5.1.
Bilateral cataract: 19, unilateral: 16, ectopia: 16.
Average age of intervention without implantation:
2.1 years (range, 1 month-6.4 years). Average age
of secondary implantation was 8.4 years (range, 2.5-
16 years). Average power: 23.5 D ± 4.1. Type of
implants: 34 SA40N, 10 ARRAY 2, 10 REZOOM.
Average time for best visual acuity: 7 ± 3.4 months.
Preoperative refraction was + 14.1 ± 1.8 D. Best far
corrected visual acuity was 0.4±1.1. Best corrected
near vision was p3 in 70%, p2 in 60%. 9 month follow-
up refraction was – 1.3 ± 0.7, for best far corrected
visual acuity 0.5 ± 1.3 (p < 0.05). Near visual acuity
was p3 in 72% and p2 in 61% (p < 0.05).
Third Group: Preoperative refraction was + 14.5 (0.5)
31° ± 1.8. Best far corrected visual acuity 0.7. Best
near vision was p3 – p4. At 9 months follow-up, best
visual acuity for the far vision was 0.7 (p < 0.05), for
near vision p3.
CONCLUSION
Lens anomaly is a clear risk for amblyopia. There is
no decided time for intervention yet chosen
internationally because of the growing axial length
and strong inflammatory response, etc. If the results
of randomized Infantile Aphakia Treatment Study
will help us to choose the most effective method for
treating infant, our study shows that multifocality
in children is a valid choice especially considering
the life activity, sport practice, and glasses
independence. The parents confirm those obser-
vations.
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1. Hunter DG. Guest editorial, Ophthalmology 2001;108(8)-
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2. Flitcroft DI, Knight-Nanan D, Bowell R, Lanigan B,
O'Keefe M. Intraocular lenses in children: Changes in
axial length, corneal curvature, and refraction. Br J
Ophthalmol 1999;83(3):265-79.
3. Dahan E, Drusedau MU. Choice of lens and dioptric
power in pediatric pseudophakia. J Cataract Refract Surg
1997;23 (suppl 1):618-23.
4. Brady KM, Atkinson CSD, Kilty LA, Hiles DA. Cataract
surgery and intraocular lens implantation in children.
Am J Ophthalmol 1995;120:1-9.
5. BenEzra D, Paez JH. Congenital cataract and intraocular
lenses. Am J Ophthalmol 1983;96:311-4.
6. Gimbel HV, Ferensowicz M, Raanan M, DeLuca M.
Implantation in children. J Pediatr Ophthalmol Strabismus
1993;30:69-79.
7. Asrani S, Freedman S, Hasselblad V, Buckley EG, Egbert
J, Dahan E, et al. Does primary intraocular lens implan-
tation prevent “aphakic” glaucoma in children? J AAPOS
2000; 4(1):33-9.
8. Russell-Eggitt I, Zamiri P. Review of aphakic glaucoma
after surgery for congenital cataract. J Cataract Refract
Surg 1997; 23(suppl 1):664-8.
9. Brady KM, Atkinson CS, Kilty LA, Hiles DA. Glaucoma
after cataract extraction and posterior chamber lens
implantation in children. J Cataract Refract Surg 1997;23
(suppl 1):669-74.
10. Lesueur L, Gajan B, Nardin M, Chapotot E, Arne JL.
Comparison of visual results and quality of vision
between two multifocal intraocular lenses. Multifocal
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11. Mc Clatchey SK. Intraocular lens calculator for childhood
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13. Hayashi K, Hayashi H, Nakao F, Hayashi F. Comparison
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14. Zetterström C. Intraocular lens implantation in the
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599-600.
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comparative study of the AMO ARRAY zonal-
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monofocal intraocular lens. Ophthalmology 1999;
106:1243-55.
16. Jacobi PC, Dietlein TS, Konen W. Multifocal Intraocular
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Ophthalmology 2001;108:1375-80.
17. Lambert SR, Fernandes A, Drews-Botsch C, Boothe RG.
Multifocal versus monofocal correction of neonatal
monocular aphakia. J Pediatr Ophthalmol Strabismus
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19. Wilson ME, Bluestein EC, Wang XH. Current trends in
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21. Mann I. The development of the human eye. Ed. 2 New-
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 Male/Female Differences Regarding Patient Satisfaction after Implantation of Multifocal IOLs
20
Male/Female Differences Regarding
Patient Satisfaction after
Implantation of Multifocal IOLs
INTRODUCTION
In the predawn darkness, the hunters have taken
up position near the lake. At dawn, a small herd of
wild horses is slowly approaching the shore. After
checking the smell and sensing no danger, all animal
wade into the shallow water to drink. Seeking
ground cover in the underbrush, the hunters
surround the drinking animals. As soon as the first
animal takes notice and raises the alarm, the hunters
leap to their feet - the animals are trapped. The
hunters throw their spears unerringly, aiming for
the wild horses’ flanks. Several of them are injured
and knocked down, to be killed by the men. Now
the women and children, who were left behind, are
notified, and they all set to work immediately. After
the men have dissected the horses, the women start
cutting the meat into thin strips. Another woman
lights the campfire and starts charcoal-grilling the
meat on a wooden skewer.
This little incident occurred during the Paleolithic
Age, 400 000 years ago, near what is now the town
of Schöningen in Germany. It was reconstructed
based on archaeological findings.
Some behaviorists insist that behavioral patterns
have remained much the same since the Stone Age.
As far as vision is concerned, this means that men,
who were originally hunters, desire a wide, clear,
uninhibited view into the far distance; while women
- avid collectors - primarily require good vision at
close range.
165
M Rau
REQUIREMENTS
There is no doubt that men and women have diffe-
rent requirements regarding reading glasses.
Women would like to use their reading glasses to
decipher small print, do handcraft, sew, and read
instruction leaflets and directions on food and medi-
cine packages. Men, on the other hand, prefer
reading the paper, crafting, and operating machi-
nery. As far as reading glasses are concerned,
women, on the average, tend to request prescriptions
involving approximately between +0.25 and +0.5
higher addition than men of the same age.
These days, women are increasingly pursuing
professional activities - is this going to affect the
reading distance? We compared the desired
optimum distance for reading books or magazines
favored by women in the 28 to 50 years age bracket
with the distance preferred by men of the same age
group. Younger women, too, tend to hold texts much
closer to their face. In this context, however, we wish
to dispense with the notion of ancient patterns of
behavior and simply maintain that women are smaller
as a rule, and that they have shorter arms.
RESULTS-HOW I CHANGED MY APPROACH
1. In the Klinische Monatsblätter 2002,1 the results
were published after implantation of a MF4 lens:
80 MF 4 lenses were implanted into the eyes of
40 patients. The MF 4 is a refractive multifocal
lens with four optical zones. The central zone is
166 Multifocal IOLs
for near vision, with a 4D addition. The MF 4 is a
one-piece, foldable, acrylic IOL.
Patients were 73 years old on the average
(extremes 58 to 82 years). Three months
postoperatively, 92% of all patients obtained an
uncorrected distance vision of 0.5 (20/40) or
better and near vision was 0.5 (20/40) or better
in 100% of all patients. 41% of patients attained a
visual acuity of 0.8 (20/25), while 45% even scored
1.0 (20/20). In this group, far vision was
satisfactory, while near vision was excellent.
Patient satisfaction was determined three
months postoperatively by an anonymous
questionnaire—30% of all patients were very
happy with the result, 64% of the questioned
patients were satisfied with the implantation and
6% were dissatisfied. These 6% unhappy patients
were all men, and they complained about
insufficient far vision (4%) and about haloes and
glare (2%).
The 30% (12) very happy patients were all
women.
The results of this study confirm that women
tend to attach greater importance to excellent
visual acuity at close range (near distance) and
appreciate the fact that they are no longer
dependent on reading glasses. We may as well
forget about the argument that women, for
aesthetic reasons, would wish to dispense with
their glasses at any cost. This age group, after
all, had reached an average age of 73 years
(Fig. 1).
Fig. 1: Woman reading distance
2. Of a total of 230 multifocal MF4 lenses implanted
by myself from 1999-2003; I had to explant four
IOLs. These lenses were replaced by monofocal
IOLs. All patients desiring the explantation were
men. The main reasons for explantation
included—complaints about poor visual acuity at
far distance, blurred, hazy, vision-important
glare, and annoying rings around the light
source.
Men are very demanding about obtaining
good visual acuity at a certain distance and are
more bothered by halos and glare (Fig. 2).
3. In order to satisfy men's requirements, I started
implanting preferentially the Amo Array into
these patients’ eyes.
The Array lens is three piece, foldable, silicon
refractive MF IOL with five optical zones, the
central zone is for far vision, and the addition is
3, 5D. Three of 280 Amo Array IOLs that I implan-
ted, had to be explanted due to glare and halos
as well as insufficient visual acuity at close range.
Again all these patients were men.
4. Since some of the male patients opted for better
visual acuity at near, I started combining the Amo
Array( refractive IOL central zone for distance)
with MF 4 (refractive IOL central zone for near)
in the same patient. With male patients, the Amo
Array was implanted first; dissatisfaction with
near vision caused the MF4 to be implanted in
the other eye, as I published in Euro Times 2003.2
5. In conjunction with a prospective study
performed between December 1999 and January
Fig. 2: Man reading distance
 Male/Female Differences Regarding Patient Satisfaction after Implantation of Multifocal IOLs
2001, I compared a population of Amo Array
patients fitted with a + ReZoom, which is a
second-generation multifocal IOL. The optical
results were comparable. The average visual
acuity obtained with the Amo Array was 0.72 at
far distance, while the ReZoom achieved a far
vision of 0.73. The average near visual acuity was
0.72 in the Amo Silicon group and 0.68 in the
ReZoom group, respectively. Contrast sensitivity
was comparable; 70% of the patient in the Amo
group observed halos-rings around the light
source, but only 36% of the ReZoom group
mentioned halos—35% of all subjects in the Amo
Array group complained about glare, while only
11% of the patients in the ReZoom group had
problems with this.
88% of all subjects in the Amo Array group
and 92% of all ReZoom patients were very
satisfied.
The majority unsatisfied AMO Array patients
had problems with poor visual acuity when
reading, while 4% of the total (all male subjects)
complained about glare and halos Dissatisfaction
in the ReZoom group was caused by insufficient
near visual acuity (7%), while only 1% of the
patients complained about glare and halos.
Male satisfaction after ReZoom implantation
was higher because of less glare and halos.
6. Between August 2005 and June 2006, we
implanted the multifocal refractive ReZoom into
160 eyes of 80 patients, 12% of the patients
complained about glare, but only 8% found this
to be troublesome—again all of these were men.
23% of all patients noticed halos, but only 13%
(10% men, 3% women) found this halo’s to be
disturbing. 30% of all patients needed glasses
after the operation, 5% (4) for far vision, 25%
(20) for near vision; 15 of these were women.
By reducing the fourth zone and optimizing
the transition zones, AMO could largely suppress
the side effects of the multifocal IOL, ReZoom -
in the glare and halos.
7. Although I have until now implanted approxi-
mately ca 500 ReZoom lenses, I have never had
to explant any of these multifocal IOLs. I attribute
this to the fact that optical side effects, glare and
halos were largely eliminated by reducing the
167
fourth refractive zone for near vision and by
optimizing the transition zones. This has also
considerably increased male satisfaction.
8. In another prospective study performed between
September 2004 and February 2005, we implanted
the Tecnis multifocal lens into 22 eyes of
11 patients after clear lens exchange. Patients
mean age was 56 years. Three months after
implantation, uncorrected far vision was 0.92,
while corrected vision was 0.98 with average
correction (0.25); 18 % of all patients mentioned
glare, but only 9% (all of them male patients)
found this to be troubling. All of the men (27%)
saw halos, but only 9% considered these to be
annoying. 18% of all patients (2 subjects) needed
glasses for computer work, since they wished to
keep a greater distance from the screen.
Female satisfaction after implantation of the
diffractive MF lens Tecnis was very high. Male
patients occasionally complained about shorter
reading distances, which was also an issue with
computer work. Two men needed a (-) prescrip-
tion for glasses. Although this patient population
also included younger professional women,
satisfaction after implantation of these refractive
multifocal IOLs was very high indeed.
DISCUSSION
These days, many women work jobs formerly
reserved to men, they operate computers and
equipment, and they practice sports. Thus, not only
dedicated, professional men, but also women at a
presbyopic age would like to achieve some indepen-
dence from their reading glasses.
Women and men obviously have different require-
ments regarding multifocal lenses. Is this surprising
at all? Women and men differ from each other.
Women are smaller, have shorter arms, therefore
hold texts closer to the eye, and they sit closer to
the computer. Women usually attach greater
importance to near vision. As regards multifocal
IOLs, women usually wish to be independent of
reading glasses. Men, on the other hand, are more
exacting about clear far vision; glare and halos are
usually considered to be much more troublesome
among male subjects.
168 Multifocal IOLs
In my opinion, higher satisfaction may be
achieved among female patients by implanting refrac-
tive multifocal IOLs with a central zone and
diffractive MF IOLs (Tecnis, Restor, Lisa). The
refractive IOL with a central zone provides vision
in the far range; the second-generation refractive
ReZoom is an IOL that will give satisfaction
especially among male patients.
Both sexes are facing ever more stringent
everyday demands; they must be able to read tiny
script on labels or instruction sheets, to decipher cell
phone and computer communications as well as
operate a variety of different equipment at the
workplace and at home and - last but not least -
drive cars, even in bad light and at night. It is not
surprising, therefore, that patient' expectations
regarding the results of refractive or cataract surgery
have increased as well.
Refractive MIOLs offer excellent vision in the
far range and the intermediate range. In my opinion,
refractive MIOLs are ideally suited for patients
reading not quite as much or only very little, who
like to drive during daylight hours, go in for a lot of
sports, do computer work, or like to play cards.
Generally speaking, persons who are active in the
intermediate range of 70 cm will profit most from
these multifocal IOLs.
Diffractive MIOLs allow good far vision and
excellent near vision and provide an excellent reading
speed. This lens is best suited for patients reading a
lot, doing handcraft and working in the near field
of vision. Since these MIOLs are pupil-independent
and allow good imaging properties over the
sphericity, even at dusk and at night, the Tecnis
ZM900 lends itself especially to patients who love
watching movies or wish to drive at night.
Patients going in for “the entire spectrum”
present a particular challenge for ophthalmo-
surgeons. They read a lot, work on the computer,
would like to drive at any given time, or go in for
sports. Which of the intraocular lenses is able to
satisfy all these requirements?
Implantation of a refractive and a diffractive
multifocal lens into the eyes of one and the same
patient is a suitable option these days regarding
optical correction in cataract patients or in cases of
refractive lens exchange - to put it briefly: “Mix and
Match”. Based on previous trend-setting successful
attempts, I returned to this topic in 2006 and
implanted 20 patients with a refractive (ReZoom)
and a diffractive (Tecnis) multifocal lens each. This
study included patients whose preoperative
refraction was between +5.75 and -5.5 and who
strongly desired independence from their reading
glasses and their distance glasses. Preoperative
refraction ranged from +5.75 to -5.50; the mean age
was 52, 2 years.
Patients enrolled in this study had no retinal and
optic nerve pathology, a strong desire to achieve
spectacle independence and the willingness to accept
possible visual side effects, halos and glare.
The average UCVA for distance was bilaterally
0.84; 0, 84 in the ReZoom eyes, o78 in the Tecnis
eyes, the mean BCVA was 0, 89, with a mean
correction of -0.33 D.
The mean intermediate (0.70 cm) UCVA was
bilaterally 0.68 and 0, 68 in the ReZoom eyes and 0,
5 in the Tecnis eyes. The mean near (30 cm) UCVA
was bilaterally 0.78; 0.68 in the ReZoom and 0, 78 in
the Tecnis eye.
To evaluate the satisfaction of the patients after
the surgery, optical side phenomenon’s and glasses
independence we asked the patients tree months
after the surgery to answer anonymously an
appropriate questionnaire. All patients were satisfied
with the optical results after the surgery. A total of
90% of patients were free of glare. Of the 10% who
had glare, only 5% found it disturbing.
Halos were experienced by 30% of our patients,
however, only 10% of these patients rated them as
disturbing when driving at night.
The rate of achieved spectacle independence was
85%. 15% of the patients needed the glasses
temporally, 5%- (1 patient) for distance, 10% (-2
patients) needed reading spectacles, it was for the
occasional small print materials (e.g., medication
leaflets) or during reading in dim lighting.
Summarizing, in my experience, I consider the
combination of the diffractive Tecnis with the
refractive ReZoom MIOL a highly effective approach
with very satisfying results.
 Male/Female Differences Regarding Patient Satisfaction after Implantation of Multifocal IOLs 169

In my opinion, the “Mix and Match” approach

provides an ideal answer to patients’ stringent
requirements and expectations, and it also makes it
possible to satisfy the specific demands of men and
women, which are quite different from each other.

PATIENT EXPECTATION
Although the differing requirements of male and
female patients regarding multifocal lenses ought
to be taken into account, individual preoperative
counseling is very important indeed. The conse-
quences associated with the implantation of a
multifocal lens should be thoroughly discussed.
What kind of job is the person doing, at what
distance are they working? Do they have to process
small parts or rather larger objects? What is the
preferred distance to the computer screen at the
office, what font size would the candidate like to be
able to see without visual aids?
At what distance does the person usually hold a
book or a paper? What kinds of sports are being Fig. 3: Magda Rau
pursued, what are the patient’s hobbies? Does he or
she need to drive often at night, or only rarely? What learn to enhance alternately one of the focal points
about increased glare sensitivity, how about and to suppress the other one. This adjustment may
occasional perception of double images? How was take up to three months.
the tolerance toward multifocal glasses? The answers The Mix and Match approach makes it possible
to these questions reveal whether the multifocal IOL for us to cater to the varying needs of patients,
is suitable at all, and if it is, which model lends itself particularly considering the differing demands of
best for the patient in question. In order to achieve male and female patients.3-8
high patient satisfaction after MIOL implantation,
thorough preoperative counseling is vital. We make SURGICAL APPROACH ACCORDING TO SEX
no absolute promises to our patients regarding
completely unaided vision under any circumstances; I (Fig. 3) use a specifically adapted approach based
instead, we emphasize the benefits of being no longer on my long-term experience with men and women.
We always resort to a two-phase approach
dependent on reading glasses. The distinct
(staged implantation); the implantation into the
possibility of needing distance glasses for driving
second eye is performed four to eight weeks later.
as well as reading glasses for particularly small print
With male bilateral cataract patients, I initially
is pointed out. Besides, possible optical side effects; implant the refractive MF IOL ReZoom into the
i.e. halos and glare, are also discussed in this context, dominant eye. Four to eight weeks later, an eye
and we talk about in how far this is compatible with examination is performed, accompanied by an in-
the patients’ everyday life. Male patients in particular depth discussion. If the patient is satisfied with the
need to go into glare and halo phenomena even more already implanted MF IOL, then I continue with this
carefully. In my experience, computer demons- type. The calculation is optimized based on already
trations have proven to be the best option. The available data. If a slight improvement of the near
patient is made aware of the fact that optical vision is desired, I calculate the refractive MF IOL
rehabilitation may be more time-consuming than slightly in the minus range of –0.5. In the case of
with monofocal lenses, since the patient needs to male unilateral cataract patients, too, I start with
170 Multifocal IOLs
the ReZoom, since I have been able to achieve
considerable satisfaction with this refractive MFIOL.
In female bilateral cataract cases, I start with the
non-dominant eye and implant a diffractive IOLs
Tecnis, ReStor or - to reduce costs - refractive lenses
with a central zone for near vision (MF45 Zeiss). If
the patient is still satisfied four to eight weeks later,
I continue with the same IOL or - if better visual
acuity in the medium or far range is desired - we
combine this with a refractive ReZoom.
Clear lens exchange is a refractive procedure
largely based on the desire to achieve the maximum
possible degree of unaided vision. With male
patients, I start with the dominant eye and select
the ReZoom for an implant. If the in-depth
consultation reveals that reading small print is a
priority, I start with the non-dominant eye and
implant a diffractive Iol, usually the Tecnis. After
subsequent examination and consultation four to
eight weeks later to obtain the patient's feedback,
suitable IOLs are selected. Bilateral implantation of
the ReZoom tends to be unsatisfactory, since the
patients, after undergoing the refractive procedure,
i.e. clear lens exchange in this case—would like to
be independent from their reading glasses.
With female subjects, I usually start with the non-
dominant eye and implant a diffractive IOLs Tecnis.
After four weeks of extensive discussions and
consultation, either the Tecnis or the ReZoom is
implanted. Female patients tend to opt for the
Tecnis. Professional women, too, attach great impor-
tance to unaided reading and are more prone to
accept minor compromises as regards far vision.
The risk of being confronted with male dissatis-
faction after MF IOL implantation is much higher
than among female patients.
Men need to be counseled much more carefully,
the desired reading distance ought to be discussed;
possible glare and halos have to be demonstrated
and talked about in great detail. Male subjects consi-
der inferior far vision, glare and halos particularly
irritating; the clear hunter’s vision is a priority.
We may question whether women are more
patient, whether they are more ready to wait, adapt
and get used to the new optical system, the multifocal
lens. Are women better able to adapt to changing
conditions? Are women more prone to avoid
conflicts and wait until adaptation has taken place?
Are women more conceited, trying at all cost to
achieve the power of unaided reading, which will
also make them look younger at the same time?
Or is it really still Ice Age behavior causing women
to be more interested in seeing details close by?
REFERENCES
1. Rau M, Bach C. Erste Ergebnisse der multifokalen Linse
MF4 Klinische Monatsblätter für Augenheilkunde,
2003;220:24-28.
2. Rau M. March: Euro Times, 2003.
3. Rau M. Variety of IOL options for treatment of
presbyopia available. Ocular surgery News 2005;23:32.
4. Rau M. Mix and match your way to better vision.
Ophthalmology Times Europe July/August 2007.
5. Rau M. Exchanging lenses for clear vision, Presbyopia
and refractive surgery with lensectomy and Tecnis
Ophthalmology Times Europe October 2006;2(8).
6. Rau M. Multifocal IOLs meets visual acuity expectation
in proper patients. 2006;17(11) November.
7. Rau M. The benefits of mix and match implantation
cataract and refractive surgery. Today Europe January/
February 2007.
8. Rau M. Mix and match your way to better vision.
Ophthalmology Times Europe July/August 2007.
 21 Mixing and Matching
Customized Approach
Tecnis-ReZoom
INTRODUCTION
Why Mixing Lenses? Why Mix and Match?
With the recent availability of multifocal and
accommodating IOLs, surgeons now have the ability
to potentially provide glasses-free vision at all
distances for our cataract and refractive lens exchange
patients. It's a very exciting time, but also a confusing
time, given the various properties of the available
IOLs in the marketplace and the varied needs and
expectations of patients. And so far, all of the new
presbyopia-correcting IOLs involve tradeoffs. Some
are better suited for distance vision, others for up-
close vision. None of them are perfect. I have been
drawn to the concept of combining two IOLs with
different optical properties to maximize the patient's
range of vision. One might consider a variety of lens
combinations, including monofocal-multifocal
Angel Lo’pez Castro
combinations. To me, mixing one diffractive and one
refractive multifocal IOL makes the most sense
intuitively, given the synergistic strengths of these
technologies, although in some patients it would be
better to customize and implant the same multifocal
lenses in both eyes. In this article, I will review what
I have learned about custom matching IOLs.
Improving Intermediate Vision
To date, my experience with custom matching has
been primarily with the combination of a ReZoom
(Advanced Medical Optics [AMO], Santa Ana, Calif.)
refractive multifocal IOL in the dominant eye and a
Tecnis (AMO) aspheric diffractive multifocal IOL in
the other eye. My original goal in combining these
lenses was to improve intermediate vision, which was
weak in patients with bilateral diffractive IOLs.
However, I also found that this combination provides
other advantages, primarily by extending the range
of vision under different lighting conditions. The
refractive ReZoom lens provides the intermediate
vision that is missing with bilateral implantation of
diffractive IOLs. In bright light, it provides superior
distance visual acuity (VA) with no loss of light
transmission, while the diffractive multifocal Tecnis
provides excellent near VA with the aspheric Tecnis
platform. In dim light, ReZoom provides better
reading capability in the middle range of the pupil.
Meanwhile, the outer portion of the Tecnis multifocal
lens becomes dominant, providing better distance
vision and decreasing night-time photic phenomena.
Thus, combining the optical properties of these two
172 Multifocal IOLs
lenses provides patients with a full range of vision
under most lighting conditions. Previously, I would
have recommended refractive lenses for light-to-
moderate readers, computer users, people who
primarily drive during the day, and those who enjoy
sports, playing cards or other indoor activities. I
would have chosen diffractive lenses for patients who
are heavy readers, drive or work at night, or who
enjoy going to the movies. But the night driver who
also uses a computer presented a difficult case
because neither option would fully meet his lifestyle
needs. The great thing about custom IOL matching is
that a diffractive- refractive IOL combination suits
most activities for any given patient, allowing you to
increase the number of candidates for multifocal IOLs
in your practice.
PREOPERATIVE TESTS
• Refraction and keratometry.
• Measurement of pupil size under mesopic
conditions (1.5 candelas/m²) and photopic
conditions (85 candelas/m²), and pupil centering.
• Examination of the lens. Phacodonesis,
subluxation
• Funduscopy macular assessment, AMD, myopic
atrophy, diabetic retinopathy, etc.
• Tear quality and quantity: tear break-up time, tear
meniscus, oily tear, mucin filaments. Fluorescein
staining.
• Corneal transparency: leucoma, dystrophies, etc.
• Topography of anterior and posterior corneal
surfaces with pachymetry to rule out patients
whose corneas do not allow for Excimer laser
surgery (ectasia, irregularities...) if necessary in the
postperative refractive adjustment.
• Ocular dominance test.
• Biometry.
LENS CHARACTERISTICS AND DIFFERENCES
Diffractive Lenses
Tecnis Multifocal
Tecnis Lens has a diffractive design going from the
center towards the edge, with steps on its posterior
surface and an anterior surface that has an aspheric
design. It features a square border both on the anterior
and posterior surfaces.
 Mixing and Matching Customized Approach Tecnis-ReZoom
Advantages
Tecnis multifocal lens is an aspheric lens whose
design provides us with the following advantages:
Regarding refractive multifocal lenses it achieves
much better near vision with adequate light.
Regarding Other Diffractive Lenses
• Good far vision is achieved in low lighting
(mesopic) conditions due to their lesser
dependence on pupil size, in addition to a lower
induction of dysphotopic phenomena at night vis-
á-vis other diffractive lenses. Having a diffractive
design from the center to the external edge of the
lens itself makes it less dependent on pupil size in
its near-far vision balance. (Multifocal lenses with
a diffractive design at the center and a monofocal
design in the outer periphery are more dependent
on the pupil size for far-near vision).
This better mesopic vision is also related to
prolate anterior surface that offsets the cornea's
positive spherical aberration. Any lens with more
than one focus is associated with some degree of
glare and halos, as one image overlaps the other
image; if we add a corneal positive spherical
aberration to this, it results in more confusion in
the foci and even greater loss of contrast sensitivity
and, therefore, of quality of vision.
• It avoids myopic changes under mesopic
conditions: in non-aspheric lenses a change occurs
towards myopia (up to 0.9 in some cases) when
the pupil is dilated from 4 to 6 mm. With the Tecnis
multifocal lens this myopic change does not occur,
delivering better far, night vision.
• It does not block light thanks to its color: apart
from blocking UV and violet light, yellow lenses
also block blue light. A lens of +20 diopters blocks
50% of blue light at 450 nm and 25% at 480 nm.
In theory, this decreases the risk of acute UV-
blue retinal phototoxicity but also rod cells visual
sensitivity. Psychophysical studies show that
filtering blue light apart from violet light decreases
scotopic vision sensitivity, although it is not
clinically determined whether this affects night
vision or not.
Although it is not demonstrated in clinical
aspects either, the lack of blue light may decrease
melatonin photoreceptors activity in the retinal
173
ganglion cells, which are related to the sleep-wake
cycle.
A sulcus may be put in place in case capsular
support is insufficient due to its three-part design.
Disadvantages
Regarding Other Diffractive Multifocal Lenses
• Silicone is a material associated to a greater
endophthalmitis rate.
• It may crack or tear during implantation. If the
surgeon detects the tear before total implantation,
it is easy to remove the lens, but if it has been
completely implanted, the lens must be torn inside
the eye or the incision must be extended so as to
remove it (given their greater dioptric power, the
thickest lenses are more likely to tear apart during
implantation).
• It is hard to explant, in case explantation is
required for any reason.
• It is less compatible with the silicone injection
in the vitreous cavity
• Since it only has ultraviolet filter, it may not
provide enough macular protection
• If a Yag laser capsulotomy is performed, the
traces of the laser impacts on the lens remain.
Regarding Other Refractive Multifocal Lenses
• They provide worse intermediate vision
• They provide a slightly worse far vision,
especially in good lighting situations (photopic)
• Less contrast sensitivity, since they have a 18%
loss of the light on the retina.
• More sensitive in terms of visual quality due to
any ocular optical abnormalities (capsular opacity,
residual graduation, ocular surface abnormalities,
etc.).
The diffractive multifocal lens is the one we choose
when we want to have good near vision; this type of
lens is ideal for reading; for the mix and match it will
be implanted in the non-dominant eye.
REFRACTIVE MULTIFOCAL LENSES
ReZoom
Refractive lenses are pupil-dependent.
In a small pupil, 80% of light is directed to the
far focus and 20% to the near focus; with a 5 mm
174 Multifocal IOLs
pupil, 60% of light is directed to the far focus, 30%
to the near focus and 10% to the intermediate focus.
Overall, the different optical zones direct more
light to the far focus than to the near one, irrespective
of pupil size. ReZoom is predominantly a lens for far
vision.
Advantages
Regarding Diffractive Lenses
• Excellent far vision. Given their optical
distribution, far vision is never compromised:
under good lighting conditions and with a small
pupil, the central part of the lens acts as a
monofocal lens for far vision, and under mesopic
conditions (dim light), with a larger pupil, as
occurs in night driving, far focus is still dominant.
• Very good intermediate vision, both under
mesopic and scotopic conditions
• Acceptable near vision under dim light
conditions.
• There are no losses in light transmission, so it
has better tolerance to residual graduations,
capsular opacities and macular or ocular surface
abnormalities.
ReZoom is the lens of choice when we want to
give priority to far and intermediate vision; it will
be implanted in the dominant eye for the mix and
match.
CHAIR TIME
Discussing it with The Patient
Suggesting a clear lens surgery with multifocal lenses
in general, and with the MIX AND MATCH method
in particular requires spending much more time with
patients when they come to our office for an
evaluation. The reason for this is that in addition to
performing the exam, we need to become familiar
with our patient's personality, occupation, and
lifestyle (daily activities), e.g. to find out whether
they are security guards or hunters, what their
priorities are regarding vision, whether they are
heavy readers or PC users, play cards or drive at
night, and whether they have any other specific visual
requirement—in other words, we must become
familiar with our patient's visual needs and
requirements. We have to explain to them what they
will be getting and what the available options are:
two monofocal lenses, monovision, two equal
multifocal lenses, either diffractive or refractive
 Mixing and Matching Customized Approach Tecnis-ReZoom
(custom match), or diffractive-monofocal and
diffractive-refractive asymmetrical implants. It is
very important to explain what outcome can
reasonably be expected, and what the postoperative
period will be like in order to rule out poor
candidates, to prevent patients’ concerns during the
postoperative period, and to prevent patient
dissatisfaction.
Before making a decision, patients should become
familiar with the available options. We must make
use of videos and/or photographs, Fig. 1 (IOL
counsellor®www.iolcounselor.com) Fig. 2, that
simulate vision with these lenses, and administer
personality questionnaires (Dr. Dell questionnaire,
http://www.crstoday.com), including questions
about each patients' visual preferences, functional
expectations, and their tolerance of visual side effects.
Before surgery we tell our patients in writing what
the advantages are that they will receive (less
dependence on glasses, improved quality of life)
along with the potential disadvantages and side
effects, including halos, glare, and loss of contrast
sensitivity.
We must make sure we have understood our
patient's wishes, and that they, too, have understood
what they will get and how that will be achieved.
Before surgery we must present to patients in
writing the advantages they will receive (less
dependence on glasses, improved quality of life) and
the potential disadvantages and side effects, including
halos, glare, and loss of contrast sensitivity.
We must make sure we have understood our
patient’s wishes, and that they, too, have under-
stood what they will get and how that will be
achieved.
What Should Patients Know Before Surgery
Regarding The Postoperative Period?
• Postoperative far vision is acceptably good within
a few days after surgery with both types of
175
multifocal lenses, especially with ReZoom, and it
continues to improve over time.
• It usually takes several weeks for near vision to
improve, especially in the ReZoom lens eye.
• Binocular ear vision continues improving beyond
a two-month-long period.
• The younger the patient, the sooner optimal near
vision is achieved.
• The patient will notice halos, glare or double
vision, especially in dim light (mesopic light
levels). This is related to multifocality, and the
second image is responsible for this problem.
Patients should be warned of the fact that
dysphotopsia is more pronounced during the first
months and may cause problems when driving at
night. It then gradually subsides because of the
neuroadaptation process, and eventually very few
patients continue to have ghosting or clinically
significant disphotopsia by six months after
surgery.
• Multifocality causes a mild loss of contrast
sensitivity (poorer vision) under mesopic
conditions. However, there are published studies
which compared contrast sensitivity six months
after surgery between eyes with monofocal and
176 Multifocal IOLs
multifocal lenses, and no significant differences
were found.
• Patients may have multifocality problems at first
(difficulties in choosing the image of interest out
of two available images), since they will require
visual retraining, but this will gradually improve
with neuroadaptation, which can take up to six
months to a year to occur.
• Reading speed may initially be reduced, but this
also improves over time, and significant
reductions are rare.
• There will be visual differences between both eyes
if the MIX and MATCH technique is used, but this
is what should be expected as the goal is to have
complementary differences between both eyes.
• For reading, good lighting is important.
• The patient will probably require a new Excimer
laser intervention in the event of clinically
significant residual refractive error.
• If there is significant preoperative corneal
astigmatism, corrective eyeglasses will be
necessary until the laser intervention is performed
(usually two months after clear lens surgery).
• Rarely, it may be necessary to explant one or both
lenses in order to solve intolerable side-effects.
What Should the Physician Know Before
Recommending Implantation of a Multifocal Lens?
• Multifocal lenses should not be offered to a
patient who is not interested in discontinuing the
use of eyeglasses.
• They should not be offered to a patient who is not
willing to accept halos.
• This procedure should not be offered to a patient
with a type A personality.
• Implantation of these lenses requires more
postoperative trips to the office, and visits usually
require increased chair time and discussions with
patients.
• The physician should anticipate potential
explanations for common complaints (be
prepared!)
• Emmetropia must be achieved: the physician
should have an Excimer laser available, either for
PRK or Lasik, and the patient must meet corneal
requirements for the procedure to be performed.
Any residual refractive error can be corrected
with laser after two months. Postoperative
ametropia greater than 0.5 diopter sphere or a
0.75 diopter cylinder is poorly tolerated,
especially in the eye with the diffractive lens. The
refractive accuracy is far more important than
when using a monofocal lens.
• Like all refractive lenses, ReZoom is more
forgiving of residual ametropia than diffractive
multifocal lenses; it works better with slightly
myopic outcomes than slightly hypermetropic
ones.
• The physician should speak clearly and honestly
with the patient.
• The physician should not mislead patients into
expecting that the results will be perfect.
• The physician should not lie to a dissatisfied
patient.
• A YAG laser should be available, since a
capsulotomy should be performed (a reasonable
time after the intervention) in case of even mild
clinically-significant capsule opacity, especially in
eyes with diffractive multifocal IOLs.
• The patient should not expect to eliminate
wearing glasses altogether, but instead expect to
achieve less spectacle dependence. This must be
emphasized, because patients may interpret the
use of glasses for very specific activities as a failure
of the surgery.
• We should have a predefined MIX and MATCH
plan that is not dependent upon the patient's
initial satisfaction or dissatisfaction with the first
eye’s result. This is because both near and far
vision will improve over time and the two IOLs
will have an additive effect).
• The refractive lens should be implanted in the
dominant eye and the diffractive lens in the non-
dominant eye.
• OCT (Carl -Zeiss Meditec, Jena, Germany) should
be available in case a patient has poor vision due
to subclinical cystoid macular edema or macular
thickening that cannot be detected with sterior
biomicroscopy.
• Many medical and surgical accommodations may
be necessary: same-day surgery for each eye,
temporary glasses for astigmatism, Excimer laser
treatment, and perhaps an early Yag capsulo-
tomy. All costs should be clearly spelled out in
the written estimates provided to the patient.
 Mixing and Matching Customized Approach Tecnis-ReZoom
• We charge a fixed global sum for the entire
process, whether complementary enhancement
procedures are required or not, since an extra
charge accompanying the extra enhancement
procedures may make the patient even more
unhappy.
• A patient's visual quality cannot be assessed with
standard high contrast optotypes, with good
ambient lighting and a miotic pupil. We should
bear in mind that even if patients have a 1.0 visual
acuity result in these conditions, they may be
bothered by halos, glare or double vision at night,
which if coupled with low contrast sensitivity may
lead to functionally poor vision and difficulties in
night driving.
Contrast sensitivity tests (Sinewave contrast
sensitivity test, ETDRS, Pelli-Robson or Regan)
performed at different ambient light levels, with and
without glare, are more representative of real-life
situations. They are very useful to simulate visual
function in the real world.
• As with all refractive procedures, dissatisfied
patients should be seen frequently, and they
should be reassured; explain to them that
outcomes typically improve over the course of
several weeks to months.
• This is still not a universally perfect solution for
presbyopia.
How to Get Started and
Who are the Best Candidates?
The initial question when I first considered mixing
dissimilar optics was whether the patient would
tolerate and integrate these disparate images. Initially,
we implanted a diffractive lens in the second eye of
patients who already had a monofocal lens in their
first eye. After reading the initial positive experiences
that others had achieved with IOL mixing, we decided
to start using the MIX and MATCH strategy, and we
have not received a single complaint so far in terms
of visual integration of both types of images. Patients
tolerate the combination of both lenses perfectly
well.
The following is a list of the best candidates for
this procedure:
• Patients who have cataracts
• Hyperopic presbyopic patients
177
• Moderately myopic presbyopes (second only to
hyperopes in terms of satisfaction rates)
• Patients who are not wearing full spectacle
correction
• Refractive patients who are contact lens intolerant
• Relatively young refractive paitents requesting
spectacle independence
• Patients who are generally tolerant, and
conformist
• Patients with a good tear film
• Patients who are not professional drivers
• Patients with low preoperative astigmatism
Poor starting candidates are refractive patients
with no cataract and with low myopia.
PATIENT SELECTION
When to Use Multifocal Lenses?
Patient selection is critically important for
multifocal implants, and is a critical determinant of
whether the procedure will be a success or failure.
Special attention should be paid to the preliminary
office consultation, in which the physician gets to
know the patient's personality and habits.
A basic premise is that patients should desire
freedom from eyeglasses, for both near and far
vision. We should always ask, "Do you really want
to stop wearing eyeglasses?" If patients say they do
not mind wearing glasses, we should implant
monofocal lenses instead.
178 Multifocal IOLs
EXCLUSION CRITERIA
A. Eye disease: multifocal lenses should not be
implanted in patients with any eye disorder.
1. Macular disease of any type.
2. Impaired ocular motility: tropias, phorias,
convergence problems, eccentric fixation or
impaired fusion due to any cause.
3. Moderate to deep amblyopia: because of the
problems they would have in near vision, since
the diffractive lens is implanted in the non-
dominant eye and this eye is used for reading.
In case of an amblyopic eye, and if patients
require uncorrected near vision (very common
in myopic people), a bilateral implant with two
diffractive lenses will be performed.
4. Moderate or severe dry eye. A patient with
poor tear quality may have poor vision,
especially in the eye with the diffractive lens.
5. Any abnormality in corneal transparency or
regularity: leukomas or ecstatic diseases
(keratoconus, pellucid marginal degeneration)
6. If pupil size is abnormally small at low light
levels (< 4-4.5 mm.) or extremely large with light
(>6 mm.).
7. Avoid multifocal implants in eyes with eccentric
pupils (since the IOL centered within the capsular
bag will not be aligned with the center of the
pupil)
8. Glaucoma: Glaucomatous neuropathy impairs
the visual perception and neuroadaptation
process. These patients in particular are poor
candidates for diffractive multifocal lenses.
9. Pseudoexfoliation: The lens may become
subluxated or dislocated during the early or late
postoperative period.
B. Related to lifestyle and occupation:
• Unrealistic visual expectations
• Patients demanding high visual requirements:
– Those who require high levels of contrast
sensitivity (pilots, photographers), especially
in dim lighting conditions (professional
drivers).
 Mixing and Matching Customized Approach Tecnis-ReZoom
– near vision high needs (neither a watchmaker
nor a jeweler are good candidates) or far
vision (sharpshooters),
– Patients who work under poor lighting
conditions (neither professional drivers nor
air traffic controllers are good candidates).
• Patients who are satisfied with their reading
glasses.
• Caution is advised with people over 70 years of
age, since their neuroadaptation may be
unpredictable.
C. Related to personality:
• Altered mental or psychiatric status of any type.
• Patients who are never satisfied with their
progressive glasses.
• Stroke.
• Dyslexia.
• Patients with type A personality (perfectionist,
intolerant, obsessive, demanding, self-critical)
D. Preoperative refraction
• Patients with low myopia or with emmetropia
and presbyopia, especially in the case of clear lens
surgery, are very poor candidates (they will
notice loss of far vision contrast sensitivity
compared with prior to correction)
• Calculation of emmetropizing lens very far from
the range of available lens powers for that eye:
Tecnis +5 to +34, Restor +10 to +30, and ReZoom
+6 to +30.
E. Surgical complications:
Relative exclusion:
• Capsular tear (the lens can still be implanted in
sulcus if it is a Tecnis or a ReZoom lens but not a
Restor one). Special care should be taken with
myopic patients because the sulcus may be larger
than normal and may increase the incidence of
luxation or lens decentration.
• Impossibility to remove a fibrous plaque from
the posterior capsule during surgery
Absolute exclusion:
• A lens that is off center (dislocated) due to any
cause should not be left in.
• A splintered or cracked lens should not be left
in.
179
KEY SUCCESS FACTORS
• Careful patient selection
• Comprehensive patient information
• Careful selection of appropriate MIOLs
• Accurate biometry with optimized A-constants
• Measures to reduce postoperative astigmatism
(LRI, LASIK touch-up)
• Clean capsule
• Tear film
• Predefined planning
• ReZoom for the dominant eye
• Emmetropia is mandatory
• Be dear and honest to the patient. Do not sell
perfection
• Do not lie to an unhappy patient
OUR RESULTS
Patients and Methods
• Group 1: Bilateral implantation of Restore n = 26
patients
• Group 2: ReZoom dominant eye, Tecnis mf non
dominant n = 28 patients
We conducted a study in which we compared
near, intermediate and far visual acuity under
different lighting conditions and with the best far
correction between two groups of patients with
similar preoperative characteristics. One group had
bilateral implants of two Restor diffractive lenses and
the other had a Tecnis diffractive lens implanted in
the non-dominant eye and a ReZoom multifocal
refractive lens in the dominant eye. Both groups were
assessed at least three months after the necessary laser
adjustments were made secondary to residual
refractions.
We conclude that:
Near vision under good lighting conditions
(photopic) and far vision in dim light (mesopic) are
very good in both groups, with no significant
differences between them.
180 Multifocal IOLs

Mesopic near vision, mesopic and photopic Clear Lens Extraction: Special Considerations
intermediate vision and photopic far vision were
I do not currently recommend multifocal lenses for
superior in the mix and match group.
emmetropic refractive patients with clear lens who
The Mix and Match group is less dependent on are only interested in not wearing reading eyeglasses.
glasses, it has a similar number of patients with Patients with previous ametropia who are
moderate or severe difficulties in night vision, and interested in refractive surgery should be warned of
these patients need fewer laser adjustments than the the risks of intraocular surgery, as compared to Lasik.
group with the diffractive bilateral implant. They should also be told that enhancement with
Excimer laser correction may eventually be required.
SUMMARY Our indications for clear lens surgery in terms of
Restor-Restor Tecnis/
preoperative refraction and age are the following:
ReZoom • Hyperopia with a spherical equivalent greater
than 4 diopters in people older than 45 years of
Near mesopic J 3.5 J 2.2
age
Near photopic J 2.0 J 1.9
• Myopia with a spherical equivalent greater than
Intermediate mesopic J 6.16 J 4.41
8 diopters in people older than 45
Intermediate photopic J 6.44 J 3.92 • Myopia with a spherical equivalent greater than
Distance mesopic 1.15 1.25 6 diopters in people older than 50
Distance photopic 1.13 1.36
Special Cases
Summary of the satisfaction survey
Pediatric cataract: We have had very positive (though
Restore- Tecnis/
Restore ReZoom limited) experience using multifocal IOLs in patients
with congenital or cortisone-induced cataracts,
Spectacle independence 84.6% 92.9%
provided that the aforementioned general premises
Non or moderate are met. We currently recommend multifocal IOLs
difficulties in night vision 69% 71%
for these younger patients because they benefit
Lasik touch up required 72% 57%
greatly from not wearing reading glasses, and they
have excellent neuroadaptation.
When to Use Custom Match?
Traumatic cataract: We also indicate the procedure if
• Bilateral ReZoom corneal transparency and regularity conditions are
– Lifestyle: mostly outdoors met and if the zonule and capsular bag are in good
– Preoperative refraction: High hyperopia state, thus allowing for proper lens centering and
– Pupil size: small stability.
– Moderate or occasional readers
– Computer users Previous refractive surgery: We do not think that prior
– Day drivers keratorefractive surgery is an absolute contra-
– Sportspeople indication to using multifocal IOLs, especially if the
– Card players, cooks, shoppers cornea can still undergo Excimer laser ablation
• Bilateral Tecnis surgery in case of lens miscalculation. This principle
– Lifestyle: heavy readers, craftspeople also holds true for eyes that have undergone prior
– Preoperative refraction: Low myopia radial keratotomy. Nowadays intraocular lens
– Pupil size: large calculation following previous Excimer laser corneal
– Night and day drivers surgery can be done using recent formulas such as
– Film lovers the Haigis -L formula, the double-K method, the
– People who work at night (guards) Best formula, and others.
 Mixing and Matching Customized Approach Tecnis-ReZoom
THE PHYSICIAN'S ATTITUDE TOWARD
A DISSATISFIED PATIENT
• Try to define the problem and act if it can be
resolved.
• Make sure that a problem truly exists
• If the cause of the patient's complaint is not clear,
perform a contrast sensitivity test, with and
without glare
• Frequent exams should be performed and
patients should be reassured (patient visits and
discussions should not be put off), and they
should not be referred to another ophthalmo-
logist. The surgeon who operated on the patient
should perform the examination.
• Patients should feel they are not alone with this
problem and that the physician cares for them and
is committed to helping them.
• Patients should be reassured that in our
experience, adverse effects usually disappear or
improve over time.
• Tell patients that dysphotopsia is inherent to
multifocality—that is the price they have to pay
for good uncorrected far and near vision. Show
patients a photograph of a multifocal lens where
the rings or the various optical zones are
displayed, and use this to explain that although
these lenses allow for far and near vision, they
cause these halos in low ambient light.
• Speak clearly and honestly with your patient.
• Do not lie to a dissatisfied patient.
• Complaints about the first eye usually improve
when the second eye is operated on.
• Avoid desperate and drastic solutions; problems
usually resolve in the first 6 months.
• If faced with a very upset patient who has an
untreatable problem inherent to the multifocal
lens, pose the following challenge: simulate for the
patient what vision with near vision with a
monofocal lens would be like, if an IOL exchange
were to be performed: most of them will back out
because they will not want to lose their near vision.
What Points Should We Check?
• Is there residual correction?
• Is the posterior capsule transparent?
• Is the lens properly centered with respect to the
pupil?
181
• Is there a quality ocular surface?
• Check tear quality and quantity.
• Rule out macular edema through OCT.
When To Explant?
If, after a reasonable time following surgery, which
may be up to one year, and after having ruled out
other causes for vision impairment in other words,
when you are convinced that the lenses are the
problem, the patient keeps complaining about halos,
doubled images, glare, acuity or definition loss, or
any other kind of problems. An exchange may be
suggested, always simulating the new situation for
far and near vision with the new lens to be implanted.
Slight lens decentration is usually not a reason for
explantation. Kazuno9 conclude in his study that up
to 1 mm decentrations in multifocal lenses do not
affect the quality of the retinal image significantly.
The lens causing the greatest discomfort should
be detected. If it is the diffractive lens (usually) and
there is good tolerance to the refractive multifocal
lens, you should discuss with the patient changing
it for a refractive lens to avoid losing intermediate
and some near vision. If the refractive lens causes
more difficulties, it should be changed for a
monofocal lens in one eye first, to assess the
situation, and then in the other eye, if necessary.
CONCLUSIONS
New multifocal lenses are increasingly used as a
surgical procedure for the treatment of presbyopia.
We have gone from using them in 2% of all lenses
implanted 3 years ago to 15%-20% nowadays.
The decision to implant these lenses requires
careful patient selection through a thorough
ophthalmologic examination, dismissing doubtful
cases. Despite being highly selective in patient
selection, some patients do not tolerate multifocality,
but we cannot know in advance who these patients
will be.
We should not confuse natural accommodation
with the “corrections for near vision” offered by
multifocality. Multifocality is not without optical
drawbacks; there is an unavoidable light loss which
translates into decreased contrast sensitivity.
182 Multifocal IOLs
BIBLIOGRAPHY
1. Bellucci R. Multifocal intraocular lenses. Curr Opin
Ophthalmol 16:33-37. ª 2005 Lippincott Williams &
Wilkins.
2. Blaylock JF, Zhaomin Si, Vickers C. Visual and refractive
status at different focal distances after implantation of
the ReSTOR multifocal intraocular lens. J Cataract Refract
Surg 2006;32:1464-73.
3. Kohnen T, Allen A, Boureau C, Dublineau F, Hartmann
C, Mehdorn E, Rozot P, Tassinari. European Multicenter
Study of the AcrySof ReSTOR Apodized Diffractive.
4. Leccisotti A. Secondary procedures after presbyopic lens
exchange. J Cataract Refract Surg 2004;30:1461-5.
5. Negishi K, Ohnuma K, Takashi Ikeda, Toru Noda Visual
Simulation of Retinal Images Through a Decentered
Monofocal and a Refractive Multifocal Intraocular Lens.
Jpn J Ophthalmol 2005;49:281-6.
6. Olson RJ, MD, Werner L, MD, Nick Mamalis N, Cionni R.
Perspectives: New Intraocular Lens Technology. Am J
Ophthalmol 2005;140:709-16.
7. Robert Monte´s-Mico, Alio JL. Distance and near contrast
sensitivity function after multifocal intraocular lens
implantation. J Cataract Refract Surg 2003;29:703-11.
8. Schwiegerling J. Recent developments in pseudophakic
dysphotopsia. Curr Opin Ophthalmol 2006;17:27-30. 2006
Lippincott Williams & Wilkins.
9. W Hütz W, H Eckhardt B, Rohrig B, Grolmus R. Reading
ability with 3 multifocal intraocular lens models. J Cataract
Refract Surg 2006; 32:2015-21.
10. Yao K, Tang X, Ye P. Corneal astigmatism, high order
aberrations, and optical quality after cataract surgery:
microincision versus small-incision. J Refract Surg
2006;22:S1079-S1082.
 22 How to Obtain Patient
Satisfaction Using
ReZoom-Tecnis and Tecnis-Tecnis?
Frank Joseph Goes

INTRODUCTION I now have experience in implanting 400 Tecnis

lenses bilaterally and another 90 mixed with the
The second generation of multifocal intraocular
ReZoom. All these eyes have a follow-up of at least
lenses (IOLs) has led to renewed interest in their
6 months.
use to correct refractive errors, particularly those
who require higher levels of refractive correction
A. MULTIFOCAL IOLs THE APPROACH
and are not good candidates for corneal refractive
surgery.1-7 Product Description: Tecnis -ReZoom Lens
The need for optimal refractive results in
younger, presbyopic patients has also opened the The Tecnis ZM 900 IOL is a 3-piece foldable
door to a new concept with multifocal IOLs—that diffractive IOL of high quality silicone with a near/
of mixing and matching different designs-(refractive far light distribution of 50/50. The diffractive
and diffractive) based on the needs of the individual component consists of 32 concentric rings-is on the
patient, in order to provide a full range of vision: back surface of the lens and provides an optical
near, distant and intermediate. In particular, the use power add of 4 D corresponding with 3.2 D at the
of the Tecnis ZM900 and the ReZoom lens provides corneal plane. The lens comes in a power range of
an opportunity to provide younger patients with +5 to + 34 D in 0.5-D steps. The –0.27-prolate anterior
functional vision without the need for spectacles.
My interest in multifocal IOL’s is not new. In my
clinical practice—the Goes Eye Center-a private out
patient surgical Centrum in Antwerp Belgium, I have
gathered experience with several types of multifocal
lenses over many years.
I started using the 3-piece, 6-mm, polymethyl-
methacrylate (PMMA) 3M multifocal intraocular lens
(IOL) in 1985. This technology was bought by Alcon
later on. From 1992, I was involved in the one-piece
refractive PMMA Storz True Vista study. In 2002, I
began using the Alcon ReStor lens. I have also
implanted 40 Crystalens IOLs from Eyeonics
company.
In 2004 I switched to the Tecnis ZM900 multifocal
IOL, and in 2006, I started combining Tecnis with Fig. 1: Characteristics of the diffractive
the ReZoom IOL (Figs 1 and 2). Tecnis multifocal IOL
184 Multifocal IOLs
Fig. 2: Characteristics of the refractive ReZoom multifocal IOL
surface compensates for the positive spherical
aberrations of the typical cornea hence resulting in
improved functional vision as reported for the
monofocal model. 8-13 This technical feature is
particularly relevant under low luminance condition
because the amount of spherical aberration increases
as the pupil size becomes larger. The light coming
into the eye is distributed between the near and far
focus, allowing a full range of vision independent
of pupil size. The lens has the Z-SHARP optic edge
technology, delaying early posterior capsular
opacification (PCO) while minimizing edge glare. The
overall diameter of the lens is 13 mm, with a 6.0-
mm optic. The lens will become available in
hydrophobic acrylic material in Europe in 2008, and
in the United States this availability is anticipated in
2008 or 2009.14
ReZoom Multifocal IOL
The ReZoom is a 3-piece acrylic multifocal IOL with
UV blocking and an OptiEdge design that is said to
minimize edge glare while reducing the potential
for posterior capsular opacification. (AMO Brochure
ref). The IOL is designed to provide for 100 percent
light transmission in order to provide the full range
of vision.
The ReZoom multifocal, with its refractive
design, has five focusing zones. From the outer edge
of the lens towards the center, these are: a low light/
distance dominant zone, a near dominant zone, a
distance zone, another near dominant zone and a
bright light/distance dominant zone. Transitions
between these zones are designed to provide
intermediate vision. with a design the company calls
“Balance View Optics,” Patients implanted with a
ReZoom multifocal are intended to have 100 percent
light transmission over all five optical zones.1
How to Select Candidates?
There are 2 groups of candidates or interested
patients.
The first group consists of cataract patients. Some
have heard about the possibility of multifocal lenses
that correct far and near vision; some have friends
or relatives who had the procedure done with
successful outcomes. These people, specifically if they
are in the 60 – 75 years old group, are very interested
in discussing this option.
 How to Obtain Patient Satisfaction Using ReZoom-Tecnis and Tecnis-Tecnis? 185
Some cataract patients have never heard about
this refractive lens concept. If we do not mention
the option of a multifocal concept, some of our
patients will be upset later on when they find out
that they have missed the opportunity to have one.
The second group consists of refractive patients
who specifically come in for refractive surgery: high
hyperopes (greater than +4 D), moderate to low
hyperopes with incipient reading problems at age
45 and older, and presbyopic patients who have
good distance vision but want to eliminate their
reading glasses.
We would not advise refractive surgery in
presbyopic myopes with a clear lens since sooner or
later a YAG laser capsulotomy will have to be done,
and we feel that the risk of complications (e.g., retinal
detachment) is higher in myopes. We would
however counsel it for myopes when there is some
cataract. We have experience in performing at least
700 YAG laser capsulotomies in our private practice
in moderate to high hyperopes and have never seen
a retinal detachment following a YAG capsulotomy.
It seems that it does not exist in this group.
Generally speaking, the cataract patient group is
less demanding than the refractive group. The ideal
candidate to start with is a moderate hyperope (2
to 5 D) between 50 and 60 years old. Be aware of
emmetropic presbyopes with good distance vision
because they are usually very demanding.
Patient Expectations
General advice such as “Underpromise and
overdeliver” and “More chair time before surgery
means less chair time after surgery” are well known,
but what do these statements actually mean? It is a
fact that our patients will always remember the very
first things we say during our discussion. They
should feel that we are confident but that we do not
want to “oversell” the product; otherwise it will
backfire and discredit the technology. I tell them
that, in the huge majority (over 95%, and I give them
my data) patients will be spectacle free after the
procedure for all distances—far, intermediate, and
near.
I tell them that some will need time (1 to 3
months) to adjust to seeing at all distances. Some
will have to get used to working closer to their
desktop and/or laptop computer and only a minority
will need to wear glasses for intermediate distances,
such as specific hobby tasks (Fig. 3). Of course
patients should be motivated and interested in
becoming spectacle free or less spectacle dependent.
Motivation is the key point; they should be willing
to be patient with the process, recognize that it may
take time to adapt to the new visual system, and
have the means to pay for the added cost of Pr-C
IOL surgery.
We are working together with AMO and my
International Colleagues on a project to filter out
those patients who will be unhappy at the end of
the journey? This may have more to do with the
patient’s personality than with the type of
accommodative or multifocal lens implanted or the
specific anatomical conditions of the eye. Results will
be presented at the next AAO 2008.
Much has been said regarding neuroadaptation
of the brain but at this point we do not have a total
understanding or a way to measure this function
before implanting a lens. We always mention that
some patients may experience problems like halos
and glare, that we cannot tell who will experience
them, and that most patients will get used to them
and will not be bothered by them after 1 to 3 months.
We also tell our patients that the lens can later be
exchanged if necessary. Of course we also discuss
the patient’s hobbies and activities such as driving
and computer work. Patients should enter the
process with a firm understanding of possible side
effects, and we let them make the final decision.
However, we recently did surgery on 2 bus drivers
with custom mixing of ReZoom-Tecnis multifocal and
they experienced no problem with night driving!
Fig. 3: Results of near vision with Tecnis MF
186 Multifocal IOLs
Why not? Because they are seated highly the truck
and look down at the upcoming car headlights and
not right into it.
Also, the disturbing subjective complaints may
decrease in many patients after a touch-up for
residual refractive errors, after implantation of an
IOL in the second eye, or –with time due to neuro-
adaptation. Halos and unwanted images will remain
significant in approximately 5 percent of patients and
this is the same for all types of multifocal IOLs. This
group of patients can still drive at night although
they may not like to do so.
Preoperative Testing
It is logical that prospective candidates for a multi-
focal lens should have normal and healthy eyes.
Diabetes (under medical control) and other syste-
matic general conditions are not exclusion criteria.
Accurate biometry (preferentially with the Iol
Master) and IOL power calculation is a “conditio
sine qua non.”especially for long myopic eyes where
there is a staphyloma, and in short eyes where
differences of 0.1 mm have an enormous impact on
the IOL power calculation.
We use at least 2, and preferentially 3, formulae
for multifocal IOL calculation: the Haigis formula;
see User Group for Laser Interference Biometry (ULIB)
Web site at http://www.augenklinik.uni-
wuerzburg.de/scripts2/ulist.php),16 combined with
Holladay II formula; both formulae are excellent for
all axial lengths. The SRK T is excellent for long
myopic eyes and the Hoffer Q formula is outstanding
for short hyperopic eyes.
The constants are constantly updated on his
website by Prof. Haigis and are 119.8 for the Tecnis
ZM900 and 118.8 for the ReZoom lens (Fig. 4).
With the Tecnis IOL, the target should be +0.25
D to plano since a myopic outcome will bring the
reading distance too close. The refractive target
should be plano with the ReZoom IOL.
Preoperative astigmatism of more than 1.5 D
should be a relative exclusion criterion for novices
since the immediate effect of the multifocal lens
would be diminished. Laser in situ keratomileusis
(LASIK) enhancement or limbal relaxing incisions
(LRIs) can solve this problem, but the patient should
be informed of that beforehand.
Fig. 4: Distance VA with the Tecnis MIOL
uncorrected best corrected
Surgical Technique
We do the surgery in our private freestanding
outpatient surgical center under topical anesthesia.
The patient is examined the day 1, day 14, and day
30 postoperatively. We choose the incision site
according to the pre-existing astigmatism; superiorly
when the astigmatism is 0.75 D or more with-the-
rule, and temporally for all other cases. We will make
the corneal incision more anteriorly when we have
2 D of astigmatism. Since LRI’s are not predictable
enough, we perform them only when the pre-existing
astigmatism is significant (more than 4 D). We use a
3.0-mm clear corneal incision made with a diamond
knife. The anterior chamber is filled with Healon
GV or Healon 5 (AMO).
The capsulorhexis should be 5.5 to 6.0 mm in
diameter and preferably central and circular. Routine
phaco emulsification was sometimes limited to
aspiration only because of the soft structure of the
patient’s natural lens. The corneal wound is
hydrated at the end of surgery and one drop of
Prednisolone acetate 5 mg/ml and polymyxin B
sulphate /3500 IE-Predmycine P®/Allergan Irvine
CA. is administered. Afterwards these drops are
continued for 4 weeks × 3 day.
The Tecnis ZM centers remarkably well by itself
due to the broad C-haptics, even with an oval or
asymmetric capsulorhexis. We never suture the
wound unless we have had to enlarge it.
 How to Obtain Patient Satisfaction Using ReZoom-Tecnis and Tecnis-Tecnis? 187
Enhancements—Complications—
Lens Exchange
When a touch-up for residual refractive error
(spherical or astigmatic) may be advisable, we prefer
to use LASIK or EpiLasik (in case of a thin or irregular
cornea) and wait until at least 3 months after surgery.
Our present enhancement rate is 10 percent, going
down from 20 percent for the first cases.
Eventual Intraocular Lens Exchange—When?
Up to this point, we have never been forced to
explant either the Tecnis or ReZoom. When faced
with an extremely unhappy patient, one should
exclude all other possibilities before considering an
IOL exchange.
A subjectively unsatisfactory outcome for the
patient may be the result of residual refractive error,
posterior capsule opacification that can be cured with
YAG laser capsulotomy, or a retinal abnormality that
can be demonstrated with optical coherence
tomography.
Even when you are convinced that the multifocal
optic is the cause of persistent complaints, try to
postpone doing an IOL exchange for as long as
possible -at least 6 months.
Implantation Technique Tecnis or ReZoom
IOL loading of these multifocal IOL’s, should be done
by the surgeon under the microscope using the
Silver Series Unfolder. The different steps are nicely
highlighted in the company brochure-that comes
with the lens. Always have a back-up lens available;
a novice surgeon will have to discard, because of
damage during the loading procedure some lenses
(around 5 to 10% Tecnis MF in the first 20, this will
drop to 1% with experience).
Carefully ensure that the lens presents itself nicely
with the leading haptic protruding toward the tip
when you advance the knob.
Use sufficient viscoelastic material such as
Healon GV or Healon 5 to fill the capsular bag.
Slowly release the IOL as you would turn a pancake
around. Once the optic becomes visible, proceed very
slowly and the lens will unfold itself. Once the optic
is in the capsular bag, retract the plunger of the
unfolder and use a Sinskey hook to deliver the
trailing haptic into the capsular bag.
Since you will have used a lot of viscoelastic take
care to thoroughly aspirate it out and go beneath
the IOL with the irrigation-aspiration tip as well.
Staged Intraocular Lens
Selection Custom Mixing
Since we have a diffractive lens -Tecnis ZM900- that
provides good distance vision and excellent near
vision and a refractive lens -ReZoom- that provides
excellent distance and intermediate vision but
performs weaker for near in our armamentarium,
we should select the multifocal lens by considering
the hobbies and professions of our patients.
Therefore, we prefer a staged implantation of the 2
eyes.
A frequent computer user may be better off with
bilateral ReZoom to provide good intermediate
range.
A professional car or truck driver who must also
drive at night will be best off with a Tecnis aspheric
monofocal IOL in both eyes.
An avid reader, such as a librarian, will be better
off with a Tecnis multifocal in each eye.
An outdoor enthusiast or golfer might be better
of with a ReZoom in each eye.
A person with strong motivation for complete
spectacle dependence will be a candidate for a mix
and match.
Surgery is done first in the dominant eye, with
the plan of operating on the second eye within 1 to
2 weeks.
Which Lens in Which Eye?
If the major activities are distance dominant,
ReZoom is implanted in the dominant eye.
If the major activities are near dominant, Tecnis
multifocal is implanted in the dominant eye.
We evaluate the first eye outcome after 7 to 10
days and query the patient about his or her
satisfaction. If he or she is completely happy, we
choose the same lens for the other eye. If a ReZoom
patient complains of inadequate near vision, we
implant a Tecnis multifocal in his or her second eye.
Finally, if a Tecnis multifocal patient complains of
inadequate intermediate vision, we may implant a
ReZoom in his or her second eye.
188 Multifocal IOLs
CONCLUSION
Although it is sometimes reported that the Tecnis
multifocal IOL does not give excellent distance vision,
all my Tecnis patients are very satisfied with their
distance vision.
After a customized mix and match approach,
some of my patients spontaneously state that the -
ReZoom eye is their “computer eye- with better
intermediate vision and that the- Tecnis eye is their
reading eye.
Data, different approaches, specific techniques
and results of using MM approach and Tecnis Tecnis
are presented in sections B and C and in detail in
published results.16,17
B. REFRACTIVE LENS EXCHANGE
CUSTOMIZING -MIXING AND
MATCHING TECNIS- REZOOM
INTRODUCTION
The concept behind “Mix and Match” is to provide
patients with the best possible range of vision
without significant visual trade off.
The most appropriate patients for the “Mix and
Match” approach are those who are motivated to
become spectacle free and are willing to accept that
there may be some optical trade-offs as results of
this approach. The best candidates will also be able
to understand the concept of the “Mix and Match”
approach and that it may take a number of months
to adapt to this new visual system.
In this study, we report on the initial visual
outcomes in 140 eyes of 70 patients implanted with
a ReZoom multifocal in their dominant eye and a
Tecnis ZM900 in their non-dominant eye.
Patients and Methods
140 eyes of 70 patients, females and males, mean
age 58 (range 44-72 years) were enrolled in the study.
In this series, implantation was determined based
on eye dominance, with all patients receiving the
ReZoom in their dominant eye, followed by
implantation of the Tecnis ZM900 in their non-
dominant eye approximately 1 to 2 weeks later. The
decision to place the ReZoom lens in the dominant
eye was made because this lens is preferentially a
distance-dominant lens.
One hundred twenty eyes were hyperopic (Range:
+0.50 to 6.75 D, Mean SE = 2.62 D, SD = 1.085 D), 12
eyes had a myopic spherical equivalent (-0.25 to -
2.50 D) and 8 eyes were 0.00 D. For all eyes, the
preoperative SE was 2.17 D (SD = 1.417 D). The mean
pre-op BCVA was 0.84, while the mean pre-op
binocular BCVA was 0.94. All patients except 10
underwent refractive lens exchange (RLE) with the
remaining patients undergoing cataract surgery with
lens replacement. Exclusion criteria included corneal
or retinal pathology and history of glaucoma or
retinal detachment.
All patients were given, reviewed and signed,
an informed consent in the presence of a nurse
witness. All other treatment options were presented,
as well as limitations and eventual secondary side
effects were discussed. This study was performed
under the accordance of the Helsinki Agreement.
IOL Power Calculation/Surgical Technique
All IOL power calculations and surgeries were
carried out by the same surgeon (FG). Biometry was
done with the IOL Master (Carl Zeiss, Carl Zeiss-
Meditec, Jena, Germany). The targeted refraction
was emmetropia to 0.25 D in the Tecnis eye and
emmetropia in the ReZoom eye.
Patients underwent either RLE or cataract surgery
on an outpatient basis using a standardized
procedure under topical anesthesia. Both eyes were
operated with a 1-2 weeks interval.
Measurements and Analysis
Clinical data was collected preoperatively, at 1 week
and 1 to 2 months and, again, at 6 months following
surgery. The testing carried out included refraction,
binocular uncorrected near, intermediate (60 cm =
24 inch) and distance vision, as well, preferential
reading distance. Patients were asked to report any
visual complaints or difficulties they experienced,
as well as their level of spectacle independence.
After surgery, patients were sent a subjective
lifestyle questionnaire.
 How to Obtain Patient Satisfaction Using ReZoom-Tecnis and Tecnis-Tecnis? 189
For this review of results in our series of “Mix
and Match,” the 6 months postoperative results are
reported; extremes 140 to 210 days, ±41.2 days).
Binocular acuities were recorded at distance,
intermediate and near using appropriate test cards.
Results were analyzed using the LogMAR acuities.
Results
At the 3 month visit results from 120 eyes of 60
patients were available; the mean SE was –0.038 D
(SD = 0.516 D).
The mean binocular distance vision was 1.06
(±0.6 SD), the mean intermediate was 0.5 (±0.9 SD)
and the mean binocular near vision was 1.1 (±0.4
SD) (Table 1) (Fig. 5).
Only one patient required spectacle correction
for reading. One patient did undergo a Lasik
enhancement procedure in both eyes to correct a
residual cylinder of -1.5 D and one needed YAG in
two eyes.
In terms of visual symptoms reported by
patients, 40/70 patients reported no subjective
disturbance by glare or halos in both eyes, 28/70
reported some glare and halo’s in both eyes, with 2
additional patients reporting halos in 1 eye only (1
OD and 1 OS). The second most frequently reported
visual symptom was day glare. Three patients
reported issues with night glare in both eyes.
The halos and glare were severe and important
in 8/70 patients and present but easily accepted in
the other 20 patients. Three patients required slightly
tinted sunglasses in order to reduce glare. The
majority of patients reporting visual side effects
indicated that visual disturbances were more
apparent at night but, in general, were not a
significant problem and improved over time. So we
still expect some amelioration.
A follow-up questionnaire was sent to all
patients following surgery to gather subjective
information regarding lifestyle after “Mix and
Match” multifocal implantation. Of the 70 patients
enrolled in the study, 46 completed and returned
the questionnaire. Topics on the questionnaire
included reading, television viewing, computer and
driving habits, as well as questions about the amount
of time needed for adapting to multifocal vision,
preferred eye (if any) and overall degree of
satisfaction.
Fig. 5: Mean near, intermediate and
distance binocular visual results
Table 1: The mean binocular UCVA results for near,
intermediate and distance shows that the best visual
outcomes for near and distance was 1.2, with no patient
worse than 0.8 at the 2-month follow-up
Decimal Mean SD Best Worst Median
Distance 1 0.6 Lines 1.2 0.8 0.8
Intermediate 0.5 0.9 Lines 0.8 0.4 0.5
Near 1.1 0.4 Lines 1.2 0.9 1.1
Analysis showed that the majority of patients with
some complaints of glare and halo are adapted very
fast (1-3 months). They did see the rings but it did
not disturb them any more. Only 6 patients could
comment on a difference of subjective complaints
between both eyes - 4/6 were more disturbed by
ReZoom 2/6 more by the Tecnis eye.
Interim analysis showed that the average amount
of time needed to adapt to their new vision was 33
± 7 days). Twenty six patients reported that they
had no preference of one eye over the other, while
6 based their preference on the UCVA results. Ten
patients preferred the vision in their ReZoom eye,
while the remaining 4 preferred the vision in their
Tecnis ZM900 eye. There did not appear to be a
correlation between patient preference and any
residual refractive error.
In terms of degree of satisfaction, 38 of the 46
respondents rated their satisfaction very good, while
6 rated it good and 2 rated it fair. When asked if
they would recommend a “Mix and Match” approach
to friends or relatives, 40 said yes, while 5 said yes,
with some restrictions regarding expectations, and
one no. In the meantime this patient is improving
since he needed reading glasses. One patient had
still problems with intermediate vision.
190 Multifocal IOLs

Some patients spontaneously indicated me their

ReZoom eye as their PC-eye and their Tecnis eye
as their reading eye.
We also looked for the differences between both
eyes-ReZoom eye and Tecnis eye.
The preferred reading distance in the ReZoom
eye was 34, 2 cm = 13.7 inches while it was 32 cm
+12.8 inches for the Tecnis eye. This is under-
standable since the effective reading add for
ReZoom is lower-2, 8 D. compared to 3.2 D for Tecnis
(Fig. 6).
We looked also at reading at intermediate
distances: at 60 cm = 24 inches: 83 percent of ReZoom Fig. 6: Preferred reading distance with Tecnis eye (RED)
eyes could read Jaeger 5-this equals newspaper print- and ReZoom eye (GREEN)
but only 41 percent of Tecnis eyes could do the same
at that distance (Fig. 7).
Also the mean reading capability at 60 cm. was
different between both eyes; the mean was Jaeger
4.5 for Tecnis and Jaeger 6.7 for ReZoom.This again
made sense, since it is well known that- because of
the design- the ReZoom allows better reading at
intermediate distances.
To date, only one patient in this series has
required a Nd: YAG capsulotomy.

DISCUSSION
Although not previously published, the concept of
mixing and matching two different types of
multifocal IOLs is not an entirely new one. Gunenc
and colleagues first presented results in 2003 of a
series of 30 cataract patients implanted with a
refractive multifocal (Array, Advanced Medical
Optics, Santa Ana, CA) and a diffractive multifocal
(811E CeeOn IOL, Pharmacia) between 2000 and
2001. (Oral Presentation, American Society of
Cataract and Refractive Surgeons, Annual Meeting,
2003, San Francisco, CA) Gunenc hypothesized that
not just one multifocal IOL could offer the majority
of patients a full range of vision.
Their results showed that 90 percent of the
bilateral group was able to function without
spectacles for near and distance tasks, compared to
60 percent in the unilateral groups. In subjective
assessments, 80 percent of the bilateral group
indicated that the results were very good to
excellent.
Fig. 7: Results intermediate distance monocular 60 cm=
42 inch: Tecnis (RED)
However, it is really only in the past year that
surgeons have begun to fully consider the potential
of mixing and matching two different styles of
multifocal IOLs. This is due to the wider availability
of second-generation multifocal IOLs that have
overcome some of the limitations of the first
generation models, including visual symptoms such
as glare and halos, as well as providing a wider
range of vision.
A number of studies reported at the 2006 ASCRS
meeting seem to highlight the potential for this
approach. Bucci reported on a series of 39 patients
implanted with a combination of ReZoom and ReStor
compared to a series that were implanted with ReStor
bilaterally (n = 55). This comparison found that the
 How to Obtain Patient Satisfaction Using ReZoom-Tecnis and Tecnis-Tecnis? 191

Table 2: Results of a comparison between eyes implanted bilaterally with 1 of 2 types of multifocal IOLs (ReStor or
ReZoom) vs. 2 groups of patients implanted using a “Mix and Match” approach (ReStor/ReZoom or Tecnis ZM900/
ReZoom).
Bilateral Bilateral ReStor and Tecnis ZM900 and
ReStor (n = 100) ReZoom (n = 100) ReZoom (n = 88) ReZoom (n = 15)
Near Vision J1.4 (30 cm) J2.3 (38 cm) J1.5 (39 cm) J1.1 (42 cm)
Intermediate Vision J3.85 J2.15 J2.3 J2.1
Distance Vision 0.8 1.0 1.0 1.0
Reading Speed 165 125 155 184
No Spectacles 89% 75% 100% 100%
Halos 1+ 2+ 1+ 1-

mix and match group had a better intermediate

vision of J2.39, compared to J3.81 in the ReStor group,
although the near vision results were almost equal
(1.06 for mix and match vs. 1.00 for the ReStor
group). (Oral presentation, ASCRS annual meeting,
March 2006, San Francisco).
Akaishi and Fabri from Brazil reported on their
comparisons of results obtained in eyes implanted
bilaterally with ReStor (n = 100) or ReZoom (n =
100) versus those seen in patients implanted with a
Mix and Match approach of the Tecnis ZM900 and
the ReZoom (n = 15) or ReStor and ReZoom (n = 88).
(Oral presentation, ASCRS Annual Meeting, San
Francisco, 2006) (Fig. 8). Fig. 8: Akaishi and Fabri 2006 results of customizing -several
The Mix and Match group combining the Tecnis combinations; the combination.Tecis-ReZoom scored best
and the ReZoom produced better visual outcomes (in green) for all factors
at intermediate distances: J2.1, ReZoom/Tecnis; J2.3,
ReStor/ReZoom; J2.15, bilateral ReZoom; and, J3.85, eyes. Further, substantially fewer patients in this
bilateral ReStor. Reading speed results were also group had no visual symptoms (glare/halos)
superior in the Tecnis/ReZoom group. Table 2 shows compared to the other group (86 vs 64%).
the full reported results.
A clinical comparison between bilateral Table 3: Outcomes from a study comparing eyes implanted
implantation of the ReStor multifocal IOL and a Mix with 1 type of multifocal bilaterally (ReStor) vs. a group
receiving a “Mix and Match” approach with Tecnis ZM900/
and Match approach using the Tecnis ZM900 and ReZoom combination
the ReZoom presented at the 2006 European Society
Bilateral Multifocal Tecnis ZM900/
of Cataract and Refractive Surgeons meeting also
IOL w/Enhancement ReZoom
showed better results in the Mix and Match eyes. (n = 36) (N = 31)
(Oral presentation, ESCRS Annual Meeting, London,
Near Mesopic J4.1 J2.4
2006). The study by Lopez Castro compared a
Intermediate Mesopic J5.3 J4.2
bilateral multifocal group of 36 eyes, which had Distance Mesopic 1.18 1.17
undergone enhancement procedures following No glare/halo 64% 86%
implantation, with a Tecnis ZM900/ReZoom group No spectacles 81% 85%
(n = 31), that had undergone no enhancements. As
shown in Table 3, the near and intermediate mesopic The results of these clinical studies do seem to
visual results were superior in the Mix and Match be supported by the initial results seen in the series
192 Multifocal IOLs

reported here. Certainly, there is a difference in the in the non-dominant eye. In this series, only one
success of second-generation multifocal IOLs patient required spectacle correction following
compared to earlier versions. multifocal implantation, although 1 patient did
undergo a LASIK enhancement to correct for
CONCLUSION residual astigmatism.
Also in 2007 in multiple papers and courses at
A study we conducted using the Tecnis ZM900 in
meetings during the year the concept of customizing
refractive lens exchange patients reflects this with
multifocal IOL’s was discussed with excellent
96.4 percent of patients reporting to be very satisfied
outcomes. Our Tables 2 and 3 demonstrate that in
with the results of the surgery at 6 months
nearly all these reports the combination Tecnis
postoperative and 92.8 percent completely spectacle
ReZoom produced the best outcomes for all
free (Goes F. Personal data 16,17 Submitted for
parameters.
publication).
The one drawback in this series was the
In our practice, patients are educated about the
requirement to wait 1 to 2 weeks between implan-
benefits and limitations of multifocal vision. Further,
tation of the ReZoom and implantation of the Tecnis
we consider their age and lifestyle: an 80-year-old
ZM900. Patients were very unhappy with the
cataract patient who has worn glasses her entire life
imbalance in vision. However, once the second eye
is not going to be bothered with still needing reading
was done, the complaints disappeared. In the future,
glasses. However, a 60-year-old who still drives and
as experience increases with these IOLs, some day
works on a computer maybe completely frustrated
bilateral implantation may be the best choice in order
to suddenly need spectacles. It is important to
to avoid this imbalance in vision.
analyze the patient’s personality to try and
The results in this series of 70 patients are very
determine as much as possible if he or she is willing
promising. The keys to success are accurate biometry,
to accept some visual trade-offs with multifocal IOLs
as well as appropriate patient selection. When these
or if they will complain of glares and halos. In our
factors are well considered, then patient satisfaction
experience, between 5 and 10 percent of patients will
can be excellent.
complain of visual symptoms regardless of the type
The mean near, intermediate and distance
of multifocal IOL implanted.
binocular visual results demonstrated excellent near
In this series, a follow-up questionnaire was sent
and distance results. Although the intermediate
to all patients after surgery in order to gain
results were not as strong, no patients required
subjective information on their vision. Of those who
spectacle correction for computer work.
responded most reported that it took just under 1
month to adapt to their new vision. No patient felt
that the visual disturbances were significant enough C. BILATERAL REFRACTIVE LENS EXCHANGE
to impact normal activities. WITH THE DIFFRACTIVE
Even with the majority of patient’s experience MULTIFOCAL TECNIS ZM900 IOL
some form of visual disturbance, 45/46 indicated in
the questionnaire that they would recommend the
ABSTRACT
approach to friends and family.
With a Mix and Match approach, it is possible to In this study we prospectively assessed visual
more closely customize vision to the needs of a outcomes and patient satisfaction after refractive lens
patient. For someone who makes his living driving exchange (RLE) followed by bilateral implantation
a taxi, for example, we implant a Tecnis monofocal of the multifocal Tecnis IOL.
IOL. In patients who are heavy readers, but don’t This case series involved 59 eyes of 30 patients
drive, then a Tecnis ZM900 multifocal is used. For aged 56±8 years. Fifty seven eyes were hyperopic
those who read, use a computer and drive, plus, (3.52±1.80 D) and 2 eyes were myopic (-1.12±0.53
strongly desire to be spectacle free, then a ReZoom D). Near, intermediate and distance visual acuities
is implanted in the dominant eye and a Tecnis ZM900 (VA) were assessed at 1 and 6 months after surgery.
 How to Obtain Patient Satisfaction Using ReZoom-Tecnis and Tecnis-Tecnis? 193

At last follow-up, patients were asked about their might be required to achieve emmetropia as well as
overall satisfaction, the occurrence of photic glasses to achieve good intermediate vision.
phenomena, difficulties driving at night and spectacle
independence. PATIENTS AND METHODS

Patient Selection
Results
This prospective case series comprised 59 eyes of 30
Six months post-surgery and after laser enhancement
patients who were eligible for RLE procedure. These
in 15 eyes, 90 percent of eyes achieved monocular
patients came to our clinic for refractive purposes
uncorrected distance VA of 20/30 or better (0.087 ±
(n=26/30) or because they wanted to be spectacle
0.085 LogMAR) and 100 percent of eyes could read
free for reading (n= 4/30). All patients were 40 years
J2 or better without correction, including 90 percent
or older. Patients were eligible for RLE when their
of eyes achieving J1 or better (0.133 ± 0.095
complaints and visual disturbances were important
LogMAR). Evaluation of visual performance
enough to make the ethical decision to discuss RLE
(Table 4) at 1-month versus 6-month (n = 44 eyes, no
surgery. The maximum accepted astigmatism was
laser) revealed a considerable improvement of the
2.5 D. Although patients aimed to be spectacle free,
uncorrected (0.175 ± 0.122 vs. 0.127 ± 0.094 LogMAR;
we counseled the patient on the possibility of
P = 0.005) and distance corrected (0.099 ± 0.057 vs.
needing glasses or to have laser touch-up after
0.068 ± 0.031 LogMAR; P = 0.001) near VA whereas
surgery. Patient psychological profile and lifestyle
mean refractive errors and distance VA remained
were also taken into account, assuming that
unchanged. Overall, 96.4 percent patients were very
perfectionists and obsessive patients as well as
satisfied with the procedure and would choose the
individuals working a lot under mesopic or scotopic
same lens again. The majority of our patients (92.8%)
conditions such as pilots, taxi-bus drivers were not
were totally free from spectacles with only
good candidates for this type of procedure.
7.2 percent of them wearing occasionally glasses for
intermediate tasks.
IOL Power Calculation
All surgeries and biometric calculations were
CONCLUSIONS
performed by the same surgeon (FG). Biometry was
The multifocal Tecnis IOL provides excellent distance performed using the IOL Master (Carl Zeiss, CZM-
and near vision after RLE and a period of Jena-Germany) and the accuracy of IOL power
neuroadaptation. However, laser vision correction calculation was evaluated using four established

Table 4: Evaluation of monocular visual performance in eyes not requiring

laser enhancement over a period of 6 months. N = 44 eyes
PARAMETERS ± 1 month ± 6 month P-values
Follow-up Follow-up 1 vs 6-month
Sphere (D) 0.50 ± 0.53 0.52 ± 0.41 0.68
Cylinder (D) -0.31 ± 0.37 -0.31 ± 0.39 0.91
Distance (LogMAR ± SD)
UCVA 0.109 ± 0.096 0.090 ± 0.094 0.09
BCVA 0.000 ± 0.039 -0.009 ± 0.053 0.23
Near (LogMAR ± SD)
UCNVA 0.175 ± 0.122 0.127 ± 0.094 0.005*
BCNVA 0.096 ± 0.056 0.074 ± 0.039 0.019*
DCNVA 0.099 ± 0.057 0.068 ± 0.031 0.001*

* Statistically significant, P<0.05

194 Multifocal IOLs
formulae15: SRK-T, Holladay I, Haigis and Hoffer
Q. The applied A constant for the SRK-T formula
was 119.4. Constants used for the Haigis formula
were as follows: ACD Constant 5.89; A0 constant
1.6; A1 Constant 0.4 and A2 Constant 0.1D. The
Hoffer Q pACD constant used was 5.89. Target
refraction was emmetropia ± 0.25 D. Eye-length
measurements were possible in all cases since no
important cataract was present in this series.
Surgical Technique
Patients were operated using standardized proce-
dure under topical anesthesia. Bilateral simultaneous
surgery was always performed on an outpatient
basis. After a 1.2 mm sideport no intraoperative or
postoperative complications were encountered.
Surgery was described elsewhere. No patient was
excluded because of surgical complications.
Measurements
Clinical data were collected before surgery and at 1
month (44 ± 17 days) and 6 months (224 ± 64 days)
after surgery. Parameters assessed included,
refractive errors, monocular near visual acuity
(UCNVA), best near corrected visual acuity
(BCNVA), distance corrected near visual acuity
(DCNVA), uncorrected distance acuity (UCVA) and
best distance corrected visual acuity (BCVA).
Distance vision was measured by Snellen visual acuity
chart at 6 meters distance. Near vision was measured
at 35 cm using the Rosenbaum pocket vision screener
(Rosenbaum, Cleveland, Ohio). Patient complaints
were recorded at the 1-3 days and 1 month visit. At
the 6-month follow-up visit, binocular defocus curve
and binocular distance corrected intermediate visual
acuity (50 and 60 cm) were assessed. A patient
satisfaction questionnaire was administered at the
6-month visit.
Depending on the refractive outcomes following
the surgery, some eyes (n=15) underwent a laser
touch-up procedure. The decision to improve the
outcomes by LASIK enhancement was made when a
refractive correction could notably improve the
BSCVA for distance and for near. It was ultimately
the patient’s decision to undergo the laser touch-up
procedure. LASIK enhancements were performed
using a routine nomogram setting with a
standardized approach.
Statistical Analysis
All visual acuity scores were converted to the
logarithm of the minimum angle of resolution
(logMAR) for statistical purposes, such as a distance
VA score of 1 = 0.00 LogMAR and a near VA score
of J1 = + 0.18 LogMAR. Results are expressed as
mean ± standard deviation (SD). Eventual changes
in visual acuity over time (1 month versus 6 months)
were assessed using the Student’s paired-t-test. Any
differences with a P. value < 0.05 were considered
statistically significant.
RESULTS
Preoperative Characteristics
Fifty nine eyes of 30 patients (14 females, 16 males)
aged 56 ± 8 years (range 34-72 years) were
implanted with the multifocal Tecnis ZM900. The
eye of one patient was amblyopic and was not
eligible for implantation. Fifty seven eyes were
hyperopic including 20 eyes with hyperopia > 4 D
(mean ± SD: 3.52 ± 1.80 D) and 2 eyes were slightly
myopic (-1.12 ± 0.53 D). Preoperative mean cylinder
was -0.39 ± 0.61 D; mean monocular UCVA was 0.23
± 0.18 (0.79 ± 0.42 LogMAR) and mean monocular
BCVA was 0.90 ± 0.12 (0.05 ± 0.06 LogMAR).
UCVA = uncorrected distance visual acuity;
BCVA = best corrected distance visual acuity;
UCNVA = uncorrected near visual acuity; BCNVA
= best corrected near visual acuity; DCNVA =
distance corrected near visual acuity.
Accuracy of IOL Power Calculation
Outcomes of IOL power calculation were analyzed
in the 57 hyperopic eyes; the mean axial length was
22.11 ± 0.92 mm. The mean prediction error
(predicted deviation minus obtained) according to
the four formulas was: –0.79 ± 0.39 D with SRK-T, -
0.35 ± 0.34 D with Haigis, -0.29 ± 0.37 D with
Holladay I and –0.28D ± 0.37 with Hoffer Q. The
percent of eyes predicted to be within ± 0.25D and
± 0.5D was respectively 13 to 25 percent with SRKT,
 How to Obtain Patient Satisfaction Using ReZoom-Tecnis and Tecnis-Tecnis? 195
21 - 51 percent with Holladay 1,38 to 61 percent with
Haigis and 36 to 69 percent with Hoffer Q formulae.
Due to some residual spherical and astigmatic
refractive errors following surgery, 15 eyes (25%)
underwent LASIK enhancement within 3 months
following the initial surgery:
All patients (n = 30) were available for the 6
months postoperative visit. Mean refractive error
was 0.51 ± 0.39 D with 42 percent of eyes within ±
0.25 D; 69 percent within ± 0.5 D and 95 percent
within ± 1 D. Mean residual astigmatism was -0.32 ±
0.36 D with 51 percent of eyes within ± 0.25 D; 83
percent within ± 0.5 D and 96.6 percent within ± 1
D. Mean uncorrected monocular distance visual
acuity was 0.087 ± 0.085 LogMAR (mean ± SD) and
improved to -0.002 ± 0.051 LogMAR with best
distance correction. Mean uncorrected monocular
near visual acuity was 0.133 ± 0.095 LogMAR and
improved to 0.080 ± 0.045 LogMAR with best near
correction and to 0.074 ± 0.039 LogMAR with best
distance correction. Binocular intermediate vision
was 0.29 ± 0.05 logMAR at 50 cm (n = 25) and 0.34 ±
0.04 logMAR at 60 cm (n = 23).
Patient Satisfaction
Patient satisfaction questionnaire revealed that halos
and glare were the most common visual disturbances
reported but decreased over time in the huge
majority. Overall, 96.4 percent patients were very
satisfied with the procedure and would choose the
same lens again: the majority of our patients (75-
96.4 %) were not disturbed by glare, halos or night
vision problems (Table 5).
Table 5: Photic Phenomena ± 6-month after Surgery
Photic Phenomenon None Moderate Severe
Annoyance from Glare 92.8% 7.2% 0%
Annoyance from Halo 75% 25% 0%
Difficulties Night Vision 96.4% 0% 3.6%
Only one patient rated his overall satisfaction as
“moderately satisfied” due to serious night driving
problems, although he would chose the same lens
again. This patient was re-checked at 12 months and
his condition had improved. The majority of our
patients (92.8%) were totally free from spectacles
with only 7.2 percent of patients wearing occasionally
glasses for intermediate tasks such as computer use.
No complications such as endophthalmitis, macular
oedema, retinal abnormalities were observed. Not
one eye needed Nd: YAG laser capsulotomy at that
time.
Discussion
In recent years, refractive lens exchange has become
an accepted alternative to LASIK or other refractive
procedures for patients with high ametropia and
presbyopia. Early concerns about the safety and
efficacy of such a procedure have been allayed by
satisfactory clinical results reported in selected
patients after implantation of monofocal or multifocal
IOLs.18-24 In this prospective case series, we report
that RLE with implantation of the Tecnis MIOL leads
to excellent visual outcomes with high spectacle
independence resulting in high patient satisfaction.
Surgeries were uncomplicated in all patients. At
the 6-month follow-up visit and after laser touch-up
in a few cases, 90 percent of the eyes achieved
monocular uncorrected distance visual acuity of 20/
30 and 100 percent of the eyes could read J2 or better
without correction. With correction, distance vision
was slightly improved and 100 percent of eyes
achieved 20/30 including 98 percent of eyes reaching
20/25. With distance and best near correction, all
eyes could read J1 or better. The huge majority of
our patients (92.8%) were totally free from
spectacles.
Visual performance after implantation of MIOLs
in RLE patients has been reported in very few
studies. In these early reports the refractive Array
MIOL was used, and visual outcomes were
satisfactory with patients achieving uncorrected
binocular distance visual acuity of about 20/40.20-22
However, although uncorrected binocular near
visual acuity was found to be comfortable, the
majority of the patients did not reach J1/J2 in contrast
to what we achieved with the Tecnis MIOL. In fact,
better near visual performance of the Tecnis over
the Array was largely anticipated due, in part, to
the 4.00 D add of the Tecnis versus 3.50 D add for
196 Multifocal IOLs
the Array. Furthermore, due to its diffractive
principle the performance of the Tecnis is
independent from pupil size in contrast to the
Array which displays its far dominant portion in
the central 2.1 mm zone. Therefore, patients with
small pupil size are likely to under perform with
respect to near vision.
So far, there has been little published clinical data
on the performance of second generation MIOLs.
Nonetheless, recent studies showed that the
advanced optic design of these new models has
resulted in better visual outcomes and higher
spectacle independence compared with former
lenses. Kohnen et al., 3 reported binocular mean
uncorrected near and distance visual acuity of 20/
25 and 20/20, respectively, six month after
implantation of the apodized diffractive ReStor
MIOL in cataract patients. Approximately 85 percent
of the individual were free from spectacles and
patient satisfaction was high. In another study,
Chiam et al.,7 showed that after ReStor implantation
in cataract patients, 93.8 and 75 percent of eyes
achieved uncorrected distance visual acuity of 20/
30 or better and uncorrected near visual acuity of
20/30 or better, respectively. Reading glasses were
required by only 2.5 percent of the patients. Similar
distance and near visual outcomes after implantation
of the ReStor MIOL were observed by others, in
cataract patients 6,7 and in a cohort of RLE and
cataract patients.4 Direct comparison between second
generation lenses and an early model has been
reported in another study in which reading ability
with the ReStor, the Tecnis and the Array MIOLs
were compared in cataract patients under different
lighting conditions.2 As anticipated the diffractive
lenses provided better reading performance than
the Array MIOL under bright light conditions.
However, when tested under low luminance, the
ReStor lens lost its superiority over the Array MIOL
while the Tecnis performed extremely well and
significantly better than the others. These data
confirm that the performance of the Tecnis is pupil
independent and reinforce the idea that its aspheric
modified prolate anterior surface is particularly
relevant under low light conditions. This is reflected
in our own study in which only one patient reported
pronounced visual difficulty at night, a condition
which improved over time.
Maybe one of the major limitations of the
diffractive design is the decrease in visual acuity at
intermediate distances. Walkow et al. 25 reported
significant superiority of the refractive design versus
the diffractive design for intermediate reading
ability. More recently, the ReStor lens has been found
to provide rather average intermediate vision in the
50 to 70 cm range.4,5,7 As a result, patients who had
to wear glasses occasionally wore them for
intermediate tasks. In the present study, we also
observed a drop in visual acuity at intermediate
distances (50 and 60 cm) with the lowest outcomes
at 60 cm. Analysis of the defocusing curve confirmed
a drop in visual acuity between -1 D to 2.5 D,
representing intermediate reading ability. However,
this loss of visual acuity seems to be clinically
irrelevant since only 7.2 percent of patients had
occasionally the need of glasses for intermediate
tasks such as computer use. These data are in line
with a study comparing defocus curves with the
Tecnis and the ReStor in cataract and RLE patients.26
The authors showed a drop in visual acuity with
both lenses at intermediate distances, however a
significant superiority of the Tecnis over the ReStor
was found at -2 D. This was reflected in the patient
questionnaire in which 9 percent of ReStor patients
reported insufficient intermediate vision compared
with 5 percent in the Tecnis group.
An alternative to improve on the intermediate
vision would be to combine the technology of two
MIOLs (mix and match) with one diffractive lens in
one eye and a refractive lens in the fellow eye as
described in section B.
It is well known that photic phenomena are
inherent to MIOLs due to multiple out-focus images.
In the present study, the self-evaluation question-
naire revealed that halos, reported by 25 percent of
our patients, were the most annoying visual
disturbance. However only 7.2 percent of patients
reported to be moderately disturbed by these photic
phenomena. In fact, as reported by others, most
patients are usually not bothered by these optical
effects which tend to fade over time. 27-29 In the
satisfaction questionnaire in which 96.4 percent of
the individuals reported no problems at night.
Overall patients were very satisfied with the
procedure and would choose the same lens again.
 How to Obtain Patient Satisfaction Using ReZoom-Tecnis and Tecnis-Tecnis? 197
Fig. 9: Binocular defocus curve of Tecnis MIOL with best
distance correction. N = 18 patients
We observed a considerable significant improve-
ment of near visual acuity between the first and six
month post-surgery whereas refractive errors
remained unchanged. In line with these data, visual
annoyance from halo and glare decreased with time.
Binocular defocus curve of Tecnis MIOL with best
distance correction is shown in Figure 9. Taken
together these data suggest a process of neural
adaptation to changes in visual information that are
supplied by the eye’s optical system. This supports
the idea that if the brain is adapted to a particular
visual pattern, when this is changed by the surgery
or lenses, the neural compensation will remain
adjusted to the first visual pattern for some time.
CONCLUSION
This clinical study provides the first information on
the safety, visual outcomes and patient satisfaction
after bilateral Tecnis MIOL implantation in RLE
patients. Our findings show that this second
generation MIOL offers improved visual acuity,
higher spectacle independence and patient satis-
faction compared with former lenses. The under-
standing of patient selection and neural plasticity is
a major step towards the full success of this
refractive technology.
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1. Lane SS, Morris M, Nordan L, Packer M, Tarantino N,
Wallace RB 3rd. Multifocal intraocular lenses. Ophthalmol
Clin North Am 2006;19:89-105.
2. Hütz WW, Eckhardt HB, Rohrig B, Grolmus R. Reading
ability with 3 multifocal intraocular lens models. J Cataract
Refract Surg 2006 ;32:2015-21.
3. Kohnen T, Allen D, Boureau C, Dublineau P, Hartmann
C, Mehdorn E, Rozot P, Tassinari G. European multicenter
study of the AcrySof ReSTOR apodized diffractive
intraocular lens. Ophthalmology 2006;113:584.e1.
4. Blaylock JF, Si Z, Vickers C. Visual and refractive status
at different focal distances after implantation of the ReStor
multifocal intraocular lens. J Cataract Refract Surg
2006;32:1464-73.
5. Chiam PJ, Chan JH, Aggarwal RK, Kasaby S. ReSTOR
intraocular lens implantation in cataract surgery: quality
of vision. J Cataract Refract Surg. 2006 ;32:1459-63.
Erratum in: J Cataract Refract Surg 2006;32:1987.
6. Sallet G. Refractive outcome after bilateral implantation
of an apodized diffractive intraocular lens. Bull Soc Belge
Ophtalmol 2006;299:67-73.
7. Souza CE, Muccioli C, Soriano ES, Chalita MR, Oliveira
F, Freitas LL, Meire LP, Tamaki C, Belfort R Jr. Visual
performance of Acrysof ReStor apodized diffractive IOL:
a prospective comparative trial. Am J Ophthalmol
2006;141:827-32.
8. Kershner RM. Retinal image contrast and functional visual
performance with spheric, silicone, and acrylic intraocular
lenses. Prospective evaluation. J Cataract Refract Surg
2003; 29:1684-94.
9. Mester U, Dillinger P, Anterist N. Impact of a modified
optic design on visual function: clinical comparative
study. J Cataract Refract Surg 2003;29:652-60.
10. Packer M, Fine IH, Hoffman RS, et al. Improved functional
vision with a modified prolate intraocular lens. J Cataract
Refract Surg 2004;30:986-92.
11. Ricci F, Scuderi G, Missiroli F, et al. Low contrast visual
acuity in pseudophakic patients implanted with an
anterior surface modified prolate intraocular lens. Acta
Ophthalmol Scand 2004;82:718-22.
12. Bellucci R, Scialdone A, Buratto L, Morselli S, Chierego
C, Criscuoli A, Moretti G, Piers P. Visual acuity and
contrast sensitivity comparison between Tecnis and
AcrySof SA60AT intraocular lenses: A multicenter
randomized study. J Cataract Refract Surg 2005;31:712-
717. Erratum in: J Cataract Refract Surg 2005;31:1857.
13. Denoyer A, Le Lez ML, Majzoub S, Pisella PJ. Quality of
vision after cataract surgery after Tecnis Z9000
intraocular lens implantation Effect of contrast sensitivity
and wavefront aberration improvements on the quality
of daily vision. J Cataract Refract Surg 2007;33:210-16.
14. Product Insert. Advanced Medical Optics, Santa Ana
CA,2006.
15. http://www.augenklinik.uni-wuerzburg.de/eulib/
index.htm.
16. Goes F. In press JRS “Refractive Lens Exchange with the
Diffractive Multifocal Tecnis ZM900 IOL, 2008.
198 Multifocal IOLs
17. Goes F. In press JRS Visual Results Following
Implantation of Refractive and Diffractive Multifocal
IOLs: A Mix and Match Approach, 2008
18. Siganos DS, Pallikaris IG. Clear lensectomy and
intraocular lens implantation for hyperopia from +7 to
+14 diopters. J Refract Surg 1998;14:105-13.
19. Vicary D, Sun XY, Montgomery P. Refractive lensectomy
to correct ametropia. J Cataract Refract Surg 1999 ;25:943-
8.
20. Dick HB, Gross S, Tehrani M, Eisenmann D, Pfeiffer N.
Refractive lens exchange with an array multifocal
intraocular lens. J Refract Surg 2002;18:509-18.
21. Packer M, Fine IH, Hoffman RS. Refractive lens exchange
with the array multifocal intraocular lens. J Cataract
Refract Surg 2002;28:421-4.
22. Preetha R, Goel P, Patel N, Agarwal S, Agarwal A,
Agarwal J, Agarwal T, Agarwal A. Clear lens extraction
with intraocular lens implantation for hyperopia. J
Cataract Refract Surg 2003;29:895-9.
23. Alio JL, Tavolato M, De la Hoz F, Claramonte P,
Rodriguez-Prats JL, Galal A. Near vision restoration with
refractive lens exchange and pseudoaccommodating and
multifocal refractive and diffractive intraocular lenses:
comparative clinical study. J Cataract Refract Surg
2004;30:2494-2503.
24. Horgan N, Condon PI, Beatty S. Refractive lens exchange
in high myopia: long term, 2004.
25. Walkow T, Liekfeld A, Anders N, Pham DT, Hartmann
C, Wollensak J. A prospective evaluation of a diffractive
versus a refractive designed multifocal intraocular lens.
Ophthalmology 1997;104: 1380–86.
26. Rozot P, Baïkoff G, Vo Tan P. Comparison des
performances visuelles des implants ReSTOR™ et
TECNIS™ multifocal. Réflexions ophtalmologiques 2005;
88 : tome 10, 12-14.
27. Dick HB, Krummenauer F, Schwenn O, Krist R, Pfeiffer
N. Objective and subjective evaluation of photic
phenomena after monofocal and multifocal intraocular
lens implantation. Ophthalmology 1999;106:1878 –86.
28. Vaquero-Ruano M, Encinas JL, Millen I, Hijos M, Cajigal
C. AMO Array multifocal versus monofocal intraocular
lenses: Long-term follow-up. J Cataract Refract Surg
1998;24:118–23.
29. Pieh S, Lackner B, Hanselmayer G, et al. Halo size under
distance and near conditions in refractive multifocal
intraocular lenses. Br J Ophthalmol 2001; 85: 816-21.
 23
AcriLISA with MICS
INTRODUCTION
Why Microincision Cataract Surgery (MICS)?
Microincision cataract surgery (MICS) was defined
as cataract surgery performed through sub 2 mm
incision.1 Advances in cataract surgery have led to
evolution of MICS technique, which gently manipu-
lates and deals with the cornea through a tiny incision,
aiming to reduce the surgical trauma and aggressive-
ness of the operated eye, for an outstanding outcome
with high patient visual satisfaction.1,2
Cataract surgery becomes one of the most fre-
quently performed surgeries in the world. Approxi-
mately, 4.5 million surgeries taking place annually
in the USA and EU. But still cataract is one of most
frequent cause of blindness in the world. New surgical
techniques and development of the tools and lenses
make the cataract surgery much saver and let patients
keep good quality of life. But still classic cataract
surgery is needed to investigate various problems
such as huge power of ultrasound energy, post-
operative astigmatism, problems with wound
leakage and also the risk of endophthalmitis. Natural
evolution of cataract surgery leads to making
incisions smaller, smaller perioperative injuries,
maximization of visual acuity and decrease the
probability of postoperative infection. That why
more and more younger patients decide to remove
cataract. They are professionally active, quite often
sight is their tool of the work. That’s why new
surgical technique and lenses should fulfill these
conditions.
Jorge L Alió, Bassam EI Kady, Pawel Klonowski
Surgery technique meeting these conditions is
MICS. MICS is the next stage in the evolution of
cataract surgery. 3 MICS was patented as a new
operating method by Jorge L. Alio in 2001. It is a
new surgery for the removal of cataracts made by
small incision in the cornea. And the main principle
is to remove cataracts with reduced aggressiveness
and trauma of the eye. MICS is the surgery
performed through incisions of 1.5 mm or less.
Understanding this global concept implies that it is
not only about achieving a smaller incision size but
also about making a global transformation of the
surgical procedure towards minimal aggressiveness.
In other words a transition from conventional small
incision surgery to the more developed concept of
MICS.4 By MICS you can operate all gradient of
cataract, subluxated lenses, post-traumatic lenses,
congenital cataracts. MICS is especially dedicated for
“refractive cataract surgery”. In general MICS does
not induce astigmatism.1 MICS should be used for
refractive cataract surgery by injecting multifocal
lenses or toric lenses. MICS is especially dedicated
for cataract surgery after corneal refractive surgery.
Why Multifocal (MF) IOL?
Multifocal (MF) IOLs lens can be used in any lens
refractive surgery including presbyopia lens
exchange (PRELEX) and for cataract surgery. They
can provide the patients with clear vision for far,
mid and near-range objects without the need for
glasses. This type of surgery has significant
202 Multifocal IOLs
advantages over other types of refractive surgery
including LASER and monovision:
• Magnification is at a natural level.
• Full peripheral (side to side) vision.
• Permanent solution to a focusing problem.
• No age limit.
• Removal of crystalline lens, with multifocal IOL
implantation provides permanent solution for
presbyopia, no way of developing cataracts as the
patients get older, and no need for continuing
change in spectacle prescription.
Added to this, that such IOLs unlike the accommo-
dating lenses available they have near and far focus
built into the lens design rather than relying on the
slightly unpredictable movement of an accommodat-
ing lens to produce near vision.
Advantages of MICS
The advantages of MICS we can consider on advant-
ages for patient and advantages for surgeon.
From the patient’s point of view focusing on is
the technique must be effective, quick, save and give
small convalescent time. MICS can fulfill these
expectations. The incision about 1.5 mm generally
does not evoke Surgically Induced Astigmatism
(SIA)1, cause the lower aberrations and the better
optical quality. Small incision technique is also much
save than classic cataract surgery. Possibility of
infection, possibility of leakage is much smaller than
in conventional surgery. Small incision, smaller
ultrasound energy means smaller inflammation.
That’s why in the first days they have very good
visual acuity and recovery time is minimal.5 After
few days they can back to work and their customary
activity. These conditions are very important for
patients and their expectations from the modern
medicine.
The surgeons center the attention on the technique
which must be safe and effective. In MICS surgeon
can find some good opportunities.
1. Small incision adequate adapted to the tools. There
is no intraoperative and postoperative leakage, no
corneal burn, and no wound destruction.
2. I/A separation is used with no wound leakage it
helps to control of intraocular pressure (IOP). In
this way fluidics work as instrument and help
surgeon on all stages of surgery. For surgeon this
kind of surgery assisted by fluidics becomes more
flexible.
3. Decreased effective phaco time (EPT) is connected
to closure anterior chamber system, I/A separa-
tion, new instrument—fluidics and more efficient
surgery.
MICS comply all conditions of modern surgery.
Small incision advantages were described well. Many
surgeons try to diminish the incision. The standard
phacoemulsification technique is also limited due to
the width of the surgical tools. Making the incision
smaller without decreasing the parameters of the flow
in the standard phacoemulsification technique isn’t
possible. But MICS technique gives comprehensive
indications and solutions of problems during surgery.
Principles of MICS are known. But thanks new MICS’s
tools surgeon can carry out safe surgery and can
prevent complications. MICS tools are made by
Katena (Katena Inc, Denville, NJ, the USA). The MICS
knifes are made to order to the shape and wide of the
incision. They have trapezoidal shape and calibrated
width. Using this tool you have a custom-made
incision. MICS irrigation tools are adapted to the
wound and they have special shape to help brake the
lens masses. Alio’s MICS Irrigating Stinger or Alio‘s
original fingernail MICS irrigating hydromanipulator
have the fluidics flow about 72 cc/min. They where
designed for huge fluidics inflow and make fluidics
flow for right way. The apex of tool is unique shaped.
It allows to elevate, cut, crush lens masses and helps
to deliver them to phaco tip or aspiration probe. MICS
Capsulorhexis Forceps is designed for perfect
manipulating in the anterior chamber during capsular
rhexis and to prevent wound destruction during this
activity. At the end of the forceps a pointed catch is
found. This enables a controlled puncturing of the
anterior bag of the lens. Pressure is applied on the
bag and then with a little movement the slice in
anterior bag is made. The wide gauged shoulder
forceps enables a free manipulation of the torn
capsular bag. Alio-Rosen Phaco PreChoppers for
Microincision Cataract Surgery are planned to divide
lens nucleus gentle and effective with out zonular
stress. Fast and effective division nuclei are
contributing for shortening the time of the operation
and delivered energy. Alio‘s MICS scissors are
designed for cutting membranes, adhesions in

anterior chamber, to make iridotomy, and also to
cut the fibrosis of bags.
Advantages of MF IOLs Associated to MICS
MICS provides cataract surgery with an astigmati-
cally neutral incision, thus reducing surgically
induced astigmatism (SIA).1,6-9 Another important
related issue, and among the major advantages of
MICS is the stabilization of corneal optics post-
surgery, as it does not change and avoids the
induction of higher order corneal aberrations
(HOA), or even effectively reduces them. Conse-
quently, the final result will be the obtaining of
incomparable high corneal optical quality with a
good final retinal image. So, the patients will gain
an excellent postoperative visual quantity and
quality, both on the immediate and long-term
outcomes.10-14.
Previous studies15-17 have reported a decrease of
the corneal optical performance following conven-
tional coaxial phacoemulsification in pseudophakic
eyes, with a significant increase in astigmatism and
higher order aberrations (such as coma, trefoil and
tetrafoil generated on the cornea)13,15 related to the
incision site and size in one part and to the optics of
IOL in the other part, depending upon the fact that
the optics of IOLs combine with the eye’s aberrations
to produce the final retinal image. So, the optics of
the cornea should remain relatively unchanged after
surgery in order to open the field for the IOL to be
effective in improving retinal image quality,13 by
negating the effect of corneal incision on changing
corneal aberrations, and rendering its role is of minor
relevance.12,13,18,19
The natural course of such surgical innovations
have opened the sky for new IOL designs to be
available, with both factors working at the same time
trying to return the patients back after cataract
surgery to high standards visual life with good satis-
faction like that of healthy subjects of a similar age.
The process of such evolution started by conven-
tional spherical IOLs designs, passing through asphe-
rical forms, until we met the patient’s visual needs
at different working distances by manufacturing the
multifocal IOLs, both in spherical and aspherical
designs, which solved to some extent the near visual
needs after crystalline lens extraction.2,17,20,21
AcriLISA with MICS 203
In summary, we like the concept of multifocal
IOLs associated to MICS because of:
• Improved visual performance for the active
patient.
• Especially important in lens refractive procedures.
• Improved control.
• More advanced better surgery.
So MICS allows:
• Full control of surgically induced astigmatism.
• Better astigmatic correction at the time of surgery.
• Less induction of corneal aberrations than coaxial
conventional phaco.
Consequently, we have to consider some impor-
tant issues, before deciding to implant multifocal
IOLs, such as:
• Abolishment of astigmatism.
• Improvement in optical performance can balance
contrast sensitivity loss.
• Not for aberrated corneas.
• Not for patients with already present contrast
sensitivity loss as: age relate macular degeneration
(ARMD), glaucoma and retinal dystrophies.
MICS MF IOLS: ACRILISA
The only one multifocal IOL that fits through MICS
incision is the Acritec 366D (AcriLISA) [Acritec
GmbH, Hennigsdorf, Germany], Table 1, Figure 1.
The AcriLISA is diffractive, bifocal, aberration
correcting, aspherical, foldable one piece lens for
capsular bag fixation and microincision (MICS).
The diffractive optic allows a splitting of the image
with some light for near and some for distance with
minimal intermediate effect. A diffractive approach
does result in 15 to 17% of the light being lost attri-
butable to random scatter. According to the company,
LISA is an acronym for light intensity distribution 65%
far and 35% near (L); independent from pupil size
(I); smooth refractive/diffractive surface profile (S);
and aberration corrected (optimized aspheric optic)
(A).
With application of a diffractive or combined
refractive-diffractive optic, the visual performance of
these new multifocal IOLs became independent of the
pupil size, which was one significant drawback of the
refractive lenses with the resultant limited near vision;
reduced contrast vision, night-time halos, glare and
204 Multifocal IOLs

well-known side effects associated with multifocal

L—Light intensity distribution 65:35
I—Independent from pupil size
S—Smooth refractive/diffractive surface profile
A—Aberration correcting
Fig. 1: Bifocal, Aberration correcting, Aspherical, Foldable one
Piece lens for capsular bag fixation and microincision (MICS)
other visual aberrations. The introduction of an
aspheric lens design in AcriLISA is one major
advancement in image quality, and it has been proven
to increase contrast sensitivity as in monofocal
lenses.22
The AcriLISA has an unequal light distribution
(i.e., 65% for distance vision and 35% for near vision).
This concept is based on that most patients prefer
distance vision and that 35% of light is sufficient for
reading quality under normal lighting conditions.
Another aim of the AcriLISA system is to reduce the
IOLs, particularly halos, by producing one dominant
and one weaker image. Furthermore, smooth steps
between the diffractive zones were engineered to
reduce glare. The bifocal lens offers good near, inter-
mediate and distance vision. This is because
aberration correction is distributed over the whole
eye. Therefore, patients have increased visual acuity
and an increased depth of focus.
Some range of pseudoaccommodation offered by
AcriLISA may allow good intermediate visual acuity.
However, such improvement may not happen
directly after surgery probably due to adaptation of
the perception of two images, especially with bilateral
implantation.23
Out of these, we can say that AcriLISA is an excel-
lent MICS IOL as it meets its requirements,24 being
implantable through a sub-2.0 mm incision without
structural or optical alteration or deformation, with
high intraocular biocompatibility and in-the-bag
stability, it does not increase the rate of posterior
capsular opacification (PCO) and has excellent optical
performance.2
CLINICAL RESULTS OF MICS
MULTIFOCAL IOLS
Clinical Data
We have investigated the outcomes of the Acritec
366D (AcriLISA) in a clinical prospective, consecutive,

Table 1: Physical characteristics of AcriTec 366D (AcriLISA)

Chapter Description
Optic size 6.0 mm
Optic size 11.0 mm
Haptic angulations 0°
Haptic design Square edged haptic and optic
Optic design Bifocal, biconvex, aspheric, aberrationcorrecting, corrects optical system (cornea,
lens) light distribution 65:35 refractive distant focus (65%) diffractive near focus
(35%) + 4.0 D power addition in the near focus
Material Foldable acrylate with 25% water content, hydrophobic surface and UV-absorber
Sterilization method Autoclaving
Avail. diopter on stock ± 0.0 D to + 32.0 D ± 0.0 D to + 10.0 D in 1.0 diopter increment + 10.0 D to + 30.0 D
in 0.5 diopter increment + 30.0 D to + 32.0 D in 1.0 diopter increment
Package In lens holder, sterile in *Acri.Pur
Suggested A-factor acoustic 118.0
Suggested A-factor optic 118.3
 AcriLISA with MICS 205

Table 2: Comparison between refractive changes for far

and near, pre- versus postoperatively
Parameter Preoperative Postoperative P value
Mean ± SD Mean ± SD
Far Vision
Mono. UCDVA 0.54 ± 0.29 0.75 ± 0.21 P < 0.001
Mono. BCDVA 0.85 ± 0.21 0.94 ± 0.11 P < 0.001
Bin. UCDVA 0.27 ± 0.23 0.89 ± 0.15
Bin. BCDVA 0.88 ± 0.16 0.96 ± 0.07

Near Vision

Mono. UCNVA 0.24 ± 0.25 0.76 ± 0.22

Mono. BCNVA 0.81 ± 0.21 (J2) 0.90 ± 0.14 (J1) P < 0.001
Mono. BCDNVA 0.77 ± 0.25 (J3) 0.90 ± 0.14 (J1)
Bin. UCNVA 0.26 ± 0.25 0.9 ± 0.15
Bin. BCNVA 0.90 ± 0.14 (J1) 0.97 ± 0.07 (J1)
Bin. BCDNVA 0.42 ± 0.18 0.95 ± 0.08 (J1)

interventional observational noncomparative clinical
trial.
Clinical Outcomes of AcriLISA 366D
Methods
• 69 eyes of 52 patients with low cataract grade
implanted with acriLisa multifocal IOL (Acri.Tec)
• The mean age was 59 years (37-74).
• The mean preoperative spherical equivalent was
+1.22 ± 3.62 D (–10.25 to +8.38 D).
• Visual and refractive outcomes were evaluated
6 months after implantation.
• Clinical data included: refractive status of the eye,
binocular uncorrected and corrected distance
(BUCVA and BCVA) and near visual acuities
(NUCVA and NCVA), both pre and post-
operatively.
Results
• Postoperative spherical equivalent: +0.39 ± 0.51
D (–0.75 to +1.50).
• Predictability: 69.32% (–0.5, +0.5 D) and 86.36%
in (–1, +1 D)
• BCVA improved significantly from 0.85 ± 0.21 to
0.94 ± 0.11 (P < 0.001). 27 (33.33%) eyes did not
show changes, 37 (45.68%) eyes gained lines and
17 (20.99%) lost lines of VA.
• NVA improved from 0.81 ± 0.21 (with addition)
to 0.90 ± 0.14 (without correction) (P < 0.001). 78
(91.76%) eyes were able to read J1 and 4 (4.71%) J2
(Table 2).
Intraocular Optical Quality
AcriLISA “In Vivo” Optical Quality Studies (Fig. 2)
Methods
• 45 eyes of 25 patients implanted with AcriLISA
366D multifocal IOL.
• The optical quality in vivo was characterized using
the VOL-CT software (version 7.11, Sarver and
Associates Inc.)
• By means of the difference between postoperative
total and corneal optical aberrations measured one
month after surgery.
• The main outcomes were total, high order,
spherical and coma intraocular aberrations (RMS
value) and Strehl ratio.
• The Modulation Transfer Function (MTF) was
obtained from the intraocular aberrations and the
spatial frequencies of the MTF cut-off and at a MTF
value of 0.5 (0.5 MTF) were calculated.
Results
For the in vivo intraocular aberrations, the mean
values and standard deviation of the RMS values
were:
206 Multifocal IOLs

Fig. 2: Imaging quality of LISA (366 D) with optimized optic (Ex vivo optic bench study)

• 1.45 ± 0.73 μm for the total RMS; 1.36 ± 0.73 μm CONCLUSION

for lower order aberrations; 0.45 ± 0.199 μm for
In conclusion, the AcriLISA 366D diffractive
high order aberrations (Figs 3 and 4).
multifocal intraocular lens offered good efficacy,
• The mean RMS of the spherical- and coma-like
predictability, safety and excellent outcomes for far
aberrations were 0.25 ± 0.10 μm and 0.37 ± 0.21
and near vision, and sufficient intermediate vision. It
μm respectively.
offered good values for the intraocular optical
• The mean Strehl ratio was 0.26 ± 0.05 (Figs 5 and
aberrations, Strehl ratio and Modulation Transfer
6).
Function, so as it provides very good MTF values at
• For the MTF:
3 and 6 mm and the aberrations related to the lens is
– The mean value of 0.5 MTF was 1.60 ± 0.63
minimal. The PSF values at 3 and 6 mm are demons-
cycles per degree (cpd).
trating an excellent quality of vision related to its
– The mean of MTF cut-off value was 50.25 ±
optical intraocular performance, added to its excellent
17.18 cpd (Figs 7 and 8).
visual and refractive outcome. Additionally, it fits well
the concept of MICS.

Fig. 3: Higher order aberrations, 6 mm pupil

 AcriLISA with MICS 207

Fig. 4: Higher order aberrations, 3 mm pupil

Fig. 5: PSF graph, 6 mm pupil

Fig. 6: PSF graph, 3 mm pupil

208 Multifocal IOLs
Fig. 7: MTF graph, 6 mm pupil
Fig. 8: MTF graph, 3 mm pupil
Finally, we can say that patient selection is crucial,
and the surgeons have to choose the appropriate IOL
which actually can meet and satisfy their patient’s
needs, especially nowadays with increasing number
of IOL designs.
REFERENCES
1. Alió J , Rodríguez-Prats JL, Galal A, Ramzy M. Outcomes
of microincision cataract surgery versus coaxial
phacoemulsification. Ophthalmology 2005;112:1997-
2003.
2. Alio J, Rodriguez-Prats JL, Galal A. Advances in
microincision cataract surgery intraocular lenses. Curr
Opin Ophthalmol 2006;17:80-93.
3. Alió JL. What is the future of cataract surgery? Ocular
Surg News, 2006;17:3-4.
4. Alió JL, Rodriguez Prats JL, Galal A. MICS microincision
Cataract Surgery. Highlights of Ophthalmology
International, Miami, 2004.
5. Wilczynski M, Drobniewski I, Synder A, Omulecki W.
Evaluation of early corneal endothelial cell loss in
bimanual microincision cataract surgery (MICS) in
comparison with standard phacoemulsification. Eur J
Ophthalmol 2006;16(6):798-803.
6. Tsuneoka H, Shiba T, Takahashi Y. Feasibility of ultra-
sound cataract surgery with a 1.4 mm incision. J Cataract
Refract Surg 2001;27:934-40.
7. Tsuneoka H, Shiba T, Takahashi Y. Ultrasonic phaco-
emulsification using a 1.4 mm incision (clinical results).
J Cataract Refract Surg 2002;28:81-86.

8. Weikert MP. Update on bimanual microincisional cataract
surgery. Curr Opin Ophthalmol 2006;17:62-7.
9. Synder A, Omulecki W, Wilczyn’ ski M, Wilczyn’ ska O.
Results of bimanual phacoemulsification with
intraocular lens implantation through the microincision.
Klin Oczna 2006;108:20-23.
10. Guirao A, Redondo M, Geraghty E, Piers P, Norrby S,
Artal P. Corneal optical aberrations and retinal image
quality in patients in whom monofocal intraocular lenses
were implanted. Arch Ophthalmol 2002;120:1143-51.
11. Holladay JT. Optical quality and refractive surgery. Int
Ophthalmol Clin 2003;43:119-36.
12. Jiang Y, Le Q, Yang J, Lu Y. Changes in corneal astig-
matism and high order aberrations after clear corneal
tunnel phacoemulsification guided by corneal topo-
graphy. J Refract Surg 2006;22:S1083-S88.
13. Guirao A, Tejedor J, Artal P. Corneal aberrations before
and after small-incision cataract surgery. Inves Ophthal-
mol Vis Sci 2004;45:4312-49.
14. Yao K, Tang X, Ye P. Corneal astigmatism, high order
aberrations, and optical quality after cataract surgery:
microincision versus small-incision. J Refract Surg 2006;
22:S1079-S82.
15. Marcos S, Rosales P, Llorente L, Jimenez-Alfaro I. Change
in corneal aberrations after cataract surgery with 2 types
of aspherical intraocular lenses. J Cataract Refract Surg
2007;33:217-26.
AcriLISA with MICS 209
16. Zeng M, Liu Y, Liu X, Yuan Z, Luo L, Xia Y, Zeng YJ.
Aberration and contrast sensitivity comparison of
aspherical and monofocal and multifocal intraocular lens
eyes. Clin Experiment Ophthalmol 2007;35:355-60.
17. Hessemer V, Eisenmann D, Jacobi KW. Klin Monatsbl
Augenheilkd. Multifocal intraocular lenses—an assess-
ment of current status.1993;203:19-33.
18. Olson RJ, Crandall AS. Prospective randomized compari-
son of phacoemulsification cataract surgery with a
3.2-mm vs a 5.5 mm sutureless incision. Am J Ophthal-
mol 1998;125:612-20.
19. Oshika T, Tsuboi S. Astigmatic and refractive stabiliza-
tion after cataract surgery. Ophthalmic Surg 1995;26:309-
15.
20. Bellucci R. Multifocal intraocular lenses. Curr Opin
Ophthalmol 2005;16:33-37.
21. Bellucci R. Biometric aspects of diffractive multifocal
intraocular lenses. Ann Ophthalmol 1992;24:374-77.
22. Mester U, Dillinger P, Anterist N. Impact of a modified
optic design on visual function: clinical comparative
study. J Cataract Refract Surg 2003;29:652-60.
23. Olson RJ, Werner L, Mamalis N, Cionni R. New intra-
ocular lens technology. Am J Ophthalmol 2005;140:709-
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24. Elkady B, Alió J, Ortiz D, Montalbán R. Corneal Optical
Quality Following Microincision Cataract Surgery
(MICS). J Cataract Refract Surg. submitted for publica-
tion.
 24
State of the Art Surgery for
Multifocal IOL Implantation
E Fabian, G Kneib, M Neunzig,U Seher, V Sipp, R Brandl

INTRODUCTION Both steps of cataract surgery, the extraction or

emulsification of the crystalline lens and the
Modern cataract surgery started 250 years ago: the
implantation of special designed IOL-optics
intracapsular extraction was performed in 1758 by J
contributed to today’s situation. With sophisticated
Daviel to restore transparency. It took 189 years that
surgery, with high standard optics of the IOL and
in 1947 the first intraocular lens (IOL) implantation
with VA at POD 1 of 100 % within a large number of
was performed by Harold Ridley to restore
patients lens surgery is replacing more and more
transparency and focusing. Further 40 years later in
corneal refractive surgery.
1987 J.Pears implanted the multifocal intraocular lens
(M-IOL). Thus lens surgery enabled surgeons to
CATARACT OR LENS SURGERY
restore all three functions of the crystalline lens:
transparency, focusing and accommodation. Cataract surgery can be divided in single steps of
the whole procedure. All these steps will be the same
Year Lens function Lens surgery Surgeon
for lens surgery. The main difference between lens
1758 Transparency Intracapsular lens J Daviel and cataract surgery is the hardness of the nucleus,
extraction despite the fact that surgeons performing M-IOL
1947 Focussing IOL-Implantation H Ridley
implantation have to perform the surgery with more
1987 Accommodation Multifocal IOL J Pears
-Implantation constancy and safety. In this respect additional items
are described in the following step by step procedure:
Lens removal surgery has been tuned to one of
Incision: Posterior limbal incisions of 3 mm are
the most successful surgeries at all. This high
inducing less than 0.5 Diopter of astigmatism.1,2 With
standard of cataract surgery enabled surgeons to
foldable M-IOL’s the incision can be less than 2,8
offer more and more patients not only to replace
mm. Wound construction has to be squared and at
the opacified lens as a therapeutic surgery, but also
least the incision should be 2 mm of length to prevent
to replace a clear lens with an intraocular lens. Thus
leakage, hypotony and endophthalmitis.3,4
cataract surgery expanded to refractive lens
exchange. Capsulorhexis has to be continuous, circular, centered
CLE Clear lens extraction and 5 mm to cover 360° of the IOL’s edge. Cannula
PreLex Presbiopic lens exchange
or forceps rhexis are suitable. The OVD maintains
the pressure in the anterior chamber and external
Relex Refractive lens exchange
pressure on the eye has to be avoided. Healon 5 can
Refractive lens exchange.
help to exist pressure onto the anterior part of the
 State of the Art Surgery for Multifocal IOL Implantation 211

lens resulting in a concave curvature of the capsule modified this technique to vertical chop. These
thus indicating the edge of the rhexis. techniques have demonstrated to be superior in
Hydrodissection needs the cannula with BSS to be respect to efficiency and to reduced delivery of U/
positioned under the edge of the anterior capsule S-sound into the eye, thus giving more space for
without injecting of BSS in the beginning, the opening safety. Modifications to horizontal or vertical chop,
of the cannula is carefully directed against the anterior to stop and chop and to prechop have been
capsule and with slight pressure BSS is now injected. proposed.
The visibility of the wavefront behind the lens Using these new technologies and modifying
confirms the hydrodissection. operation technique there had been proposals for a
different way of aspiration and emulsification
Hydrodelineation, to separate epinucleus and especially in nuclei being not to hard.7 This technique
endonucleus material, is performed more centrally. can be adjusted to different hardnesses of the nuclei.
Both maneuvers are repeated 2 or 3 times resulting For very soft nuclei rolling or carousselling can be
in rotation of the nucleus. used for the whole nucleus. Medium nuclei can be
carpooled after chopping the nucleus into 2 halves,
U/S-Phaco Emulsification hard nuclei can be carousseled after chopping the
Modern phaco technology and technique needs the nucleus into 4 quadrants (Fig. 1).
partition the two components of phaco surgery of
power and fluidics. Power is the combined effect of
cavitational and jackhammer energy. Fluidics
includes the management of vacuum and flow.
Both parts have dramatically changed within the
last years. Power modulation and WhiteStar
Technology helped to dramatically reduce the energy
needed to emulsify the nucleus. Management of
fluidics with digitally driven peristaltic pumps, with
sensing the pressure in the anterior chamber and with
CASE technology helped to rise followabilty and to
reduce surge.
The latest development in phaco technology is
torsional (Ozil, Alcon)and rotational (Eclpise, AMO)
phaco tip movement. Up to now the phaco energy
has been generated by longitudinal movements of the
tip (21-42 kHz). The torsional movement of the
angulated Kelman tip helped to emulsify the nucleus
more effectively. But torsional and longitudinal can Fig. 1: Demonstrating how carousselling is adopted to the
not be used simultaneous. With rotational, to be used different hardnesses of the lens material
simultaneous with longitudinal an additional amount
of effect is generated in combination with WhiteStar. Phaco Caroussel Technique
All these developments in technology are steps
into the direction of computer controlled phaco Positioning the phaco tip to the peripheral part of
surgery. Knowledge of experienced surgeons has the nucleus after hydrodissection and hydro-
been transferred into machine technology to delineation, rotating the 30° tip to the side, lens
anticipate intraoperative situations. But, there is still material is occluding to the tip and then aspirated.
space to further enhance operation techniques. This forces the lens material to rotate. The whole
In 1993 Nagahara5 first introduced the concept nucleus can thus be aspirated, assisted by very small
of phaco chop in a horizontal way. In 1995 Fukasaku6 amounts of ultrasound power (Figs 2A to D).
212 Multifocal IOLs
Figs 2A to D: Soft nucleus is aspirated at the periphery (A), the 30° tip rotated to the side,after aspirating and
emulsifiying the nucleus (B and C), residual cortical material (D) is aspirated also with the phaco tip
Medium-hard nucleus is first chopped into to
halves, the tip than aspirates the peripheral, softer
cortical material of the first half and than aspirates
the lens material with help of ultrasound power. The
same is done with the second half (Figs 3A to D).
Hard nucleus is first chopped into 4 quadrants,
the tip than aspirates the peripheral, softer cortical
material of one quadrant, than aspirates the lens
material with help of ultrasound power. The same is
done with the three other quadrants (Figs 4A to D).
After this the residual cortical material can also
be aspirated with the phaco tip. Very stable anterior
chamber, generated by fluidics management with
CASE technology and by very rapid sensing and
reacting for pump speed, helps to remove lens
material very effective and safe.
For the first time, the same phaco technique can
be used for different tips of lens or cataract material.
M-IOL Implantation
Multifocal, flexible IOL’s can be implanted through
an incision of less than 3 mm. They are folded in a
cartridge and implanted with an injector. Thus
optimizing safety, predictability and direct
positioning of the IOL into the capsular bag.
Surgical Media Center
The new Surgical Media Center adds another level
of efficiency. The well known overlay showing phaco
data on the screen has been further developed to a
media center. Images of fig 2-4 are created with the
SMC. Graphs of power (yellow), of flow (blue) and
of aspiration (green) indicate the actual parameters
and give an overview of 30 seconds. Continuous
taping of surgeries with video images and curves of
parameters helps for later detailed analysis image
 State of the Art Surgery for Multifocal IOL Implantation 213

Figs 3A to D: Medium nucleus is choped into 2 halfes (A) and one is aspirated at the periphery, (B) the 30° tip is
rotated to the side, after aspirating and emulsifiying the nucleus (C), residual cortical material (D), is aspirated also
with the phaco tip

Figs 4A to D: Medium-hard nucleus is choped into 4 quadrants (A) and one is aspirated at the periphery
(B), the 30° tip is rotated to the side, the quadrant is emulsified and aspirated by carousselling (C and D)
214 Multifocal IOLs
by image. Easy editing of videos, reviewing case by
case and documentation for management of quality
is now available.
Discussion
Phaco surgery today is more than ever monitored
under diverging aspects by public and health care
institutions. Forces for constant less reimbursement
on the one side and whishes for more refractive lens
exchange on the other side are influencing the fight
between safety and efficiency. Control of the
intraoperative situations by help of machine
technology and of surgeons experience in technique
is mandatory for excellent quality of surgery and
outcome of patient’s vision, also at day 1 post-
operative. Efficiency is more and more required.
WhiteStar Signature is designed for that in expanding
safety margins for today’s lens removal technique,
including multifocal IOL implantation with
conventional coaxial or bimanual biaxial MICS for
cataract and refractive surgery
REFERENCES
1. Vass C, Menapace R. Computerized statistical analysis
of corneal topogrpahy for the evaluation of changes in
corneal shape after surgery. AM J Ophthalmol 1994;
118:177-84.
2. Rainer G, Menapace R, Vass C, Annen D, Findl O,
Schmetterer K. Corneal shape changes after temporal and
superolateral 3.0 mm clear corneal incision. J Cataract
Refract Surg 25;8:1121-6.
3. Fine H. Corneal tunnel incision with temporal approach.
In: Fine H, Fichmann RA, Grabow HB (Eds): Clear
Corneal Cataract Surgery and Topical Anaesthesia.
Thorefare NJ: Slack, Inc; 1993;25
4. Masket S, Belari S. Proper wourd construction to prevent
short-term ocualr hypotony after clear corneal incision
cataract surgery. J Cataract Refract Surg 2007;33:383-6.
5. Nagahara K. Phaco Chop film. Presented at:
International Congress on Cataract, IOL, and Refractive
Surgery. ASCRS, May 1993; Seattle, Wash.
6. Fukasaku H. Snap and split phaco technique safely
cracks the nucleus. Ocular Surgery News International
Edition 1995;6(8):5.
7. Güell JL, Vázques M, Lucena J, Velasco F, Manero F.
Phaco rolling technique. J Cataract Refract Srug
2004;30(10):2043-5.
 Laser Enhancement After Multifocal IOL Implantation
25
Laser Enhancement After
Multifocal IOL Implantation
Refractive lens exchange or modern cataract surgery
are refractive surgical procedures designed to provide
spectacle independence and possibly even the
correction of higher order aberrations. Surgeons will
use a combination of aspheric and multifocal IOLs
with wavefront-driven ablations to achieve perfect
vision.
Lens surgery alone will not be sufficient to achieve
spectacle independence in all patients. We should
therefore consider lens surgery and refractive laser
surgery as a “combination package” because we
cannot offer emmetropia to every patient without
some enhancements. For example, refractive lens
surgery should include the lens exchange surgery,
with or without cataract, and possibly a fine-tuning
with LASIK, Epi-LASIK or another method of corneal
refractive surgery. The laser procedures are usually
done a few months after the initial lens replacement
surgery. By looking at these procedures as a package
for the patient, we can provide excellent results as
well as increased patient satisfaction.
LENS SURGERY
Part one of the package is the lens surgery. As
spectacle independence is usually what my patient’s
request, I will typically implant a multifocal IOL (a
procedure also known as “presbyopic lens exchange
(PRELEX)”). Out of the many multifocal IOLs
available, I prefer to use either the ReZoom multifocal
IOL or the Tecnis aspheric multifocal IOL.
The ReZoom multifocal IOL is a refractive,
distance-dominant multifocal IOL, based on the
215
Michael C Knorz
multizone-design of the Array multifocal IOL, which
was the first multifocal IOL approved in the United
States. It features five optical zones and has a 3.5 D
near add, equivalent to about 2.8 D at the spectacle
plane, but it has a much lower incidence of halos than
the Array IOL. In a comparison of the ReZoom and
the Array, there was an incidence of only mild halos
with the ReZoom, while there were some problems
with moderate-to-severe halos with the Array.
Therefore, the design change of the ReZoom is visible
clinically over the Array as well. Being a distance-
dominant multifocal IOL, the ReZoom provides
excellent distance vision. In addition, intermediate
vision is usually quite good, while near vision is
somewhat lower, and a certain number of patients
will require a near add if the ReZoom IOL is
implanted in both eyes. Typically, vision at “laptop
distance” is good, while this distance is not as good
with both the Tecnis multifocal IOL and the ReStor
multifocal IOL.
The Tecnis multifocal IOL is an aspheric
diffractive multifocal IOL, featuring a prolate
surface, designed to compensate the spherical
aberration of the average cornea, and a diffractive
back side with a near add of +4 D, equivalent to an
add power of about 3.2 D at the spectacle plane.
Light distribution to distance and near focus is 41%
each, with 18% of light distributed to higher orders
of diffraction. Both the distance and near focus are
very distinct, meaning that there is a drop of visual
acuity at intermediate distances. Near vision is
typically excellent in every patient, and the maximum
216 Multifocal IOLs
is achieved at about 34 cm. Distance vision is also
good, but intermediate vision is somewhat lower
due to the design of the IOL.
Mix and Match – My Approach
My typical approach is to use a staged implantation
with the option of mixing the two different IOL
designs. Most patients in my practice require good
distance vision and some intermediate vision. In these
patients, I start with the dominant eye and implant a
ReZoom multifocal IOL. After surgery, I will discuss
the reading capabilities with this IOL with the patient.
In about 50-60% of cases, reading vision will be
described as satisfactorily, and I will then implant a
ReZoom IOL in the non-dominant eye, too. I will,
however, aim for -0.25 to -0.5 D in the non-dominant
eye instead of +0.25 D as compared to the first,
dominant, eye. Should, on the other hand, the patient
describe his near vision as insufficient, I will implant
a Tecnis multifocal IOL in the non-dominant eye. In
the US, where the Tecnis multifocal IOL is not
available yet, a ReStor IOL may also be used. The
ReStor also provides excellent near vision but a
significant drop at intermediate distances. However,
near vision in dim light is lower with the ReStor than
with the Tecnis multifocal IOL.
Patient Selection
The first and key question, for all potential patients
is whether or not they mind to wear glasses. Patients
who do not mind glasses are usually poor candidates
because they are less likely to tolerate the visual side
effects inherent to any multifocal IOL. The second
question is whether those patients who do not want
to wear spectacles are willing to accept “a price to be
paid” for this, the “price” being the visual side effects.
Ideal candidates are usually hyperopic patients; they
are the most grateful patients for multifocal IOLs and
more willing to accept visual side effects. In general,
high myopes are also suitable patients. However,
keep in mind that low myopes, again with or without
cataracts, should be the last choice because they are
not very good candidates for multifocal technology.
How can we exclude the “unhappy” multifocal IOL
patient? In my experience, it is very helpful to use a
contact lens trial with multifocal contact lenses in
patients in whom I am not sure whether they will
like the multifocal IOL or not. A contact lens trial
will obviously not work in cataract patients, but it
works well in refractive patients. I use it routinely
in low hyperopes, high myopes, and low myopes as
well as in all very critical patients.
Which Refractive Errors Should be Treated?
Residual refractive errors are the indication for
additional laser vision correction. As a general rule,
of course, it is not the refractive error that triggers
the laser enhancement, but the unhappy patient. If
the patient is happy with his vision, no treatment
should be performed, even if there is a significant
refractive error. On the other hand, even small
refractive errors may lead to unhappy patients with
multifocal IOL. Multifocal IOLs are far more critical
regarding postoperative refraction than monofocal
IOLs. An astigmatism of 0.75 D will usually not
adversely affect vision in a patient with a monofocal
IOL, but may lead to a significant reduction in
uncorrected vision in a patient with a multifocal IOL.
If a patient is unhappy AND some residual ametropia
is present, it is therefore advisable to perform laser
vision correction. If unsure, a contact lens trial can
always be performed.
Prior to the laser vision correction, the clarity of
the posterior capsule must be assessed. It is again
important to remember that multifocal IOLs are far
more critical than monofocal IOLs regarding capsule
opacification. Even small amount of capsule
opacification may reduce vision with multifocal IOLs.
Therefore, if a patient is unhappy and some capsule
opacification is visible, a YAG capsulotomy should
be performed prior to any laser vision correction. This
is especially important if a customized laser vision
correction is considered, as wavefront measurements
are affected by capsule opacification.
Customized Laser Vision Correction
Part two of the “package” is the, if possible
customized, laser vision correction. LASIK or Epi-
LASIK (or PRK) are performed about three months
after lens replacement surgery. I use the VISX Star S4
IR excimer laser and its “CustomVue” customized
procedure in most cases. The system uses Fourier-
 Laser Enhancement After Multifocal IOL Implantation
based Wavefront evaluation, which provides much
greater detail than the historic Zernike-based
analysis. The VISX system also provides perfect
alignment of WaveScan measurement and laser
ablation, which is a critical component in the success
of the procedure. In addition to the pupil-based eye
tracking, the alignment with the VISX system (called
“iris registration”) compensates both for the eye
rotation and the pupil centroid shift. Therefore, a
perfect match is achieved between the laser treatment
and the wavefront measurement. The laser vision
correction can obviously also be performed using a
standard ablation based on phoropter refraction. This
is also the preferred approach whenever a ReZoom
multifocal IOL was implanted in the respective eye,
as will be explained in detail later. The basic idea of
the bioptics “package” is to implant a multifocal IOL
and correct any clinically significant refractive error
using laser refractive surgery, standard, wavefront-
optimized, or customized.
Why Customized Ablation?
The rational to use a custom ablation is the matching
of the planned treatment with the actual ablation on
the eye. This perfect match will improve the
predictability of the astigmatic correction as well as
the centration of the ablation. Therefore, the outcomes
of refraction will be better as astigmatism is corrected
more precisely. In addition, a customized ablation
Fig. 1: Effect of axis misalignement on retinal image in 1D of astigmatism
217
may ideally decrease higher-order aberrations, or
at least minimize the induction of these aberrations.
IRIS REGISTRATION
Iris registration is the term used to describe the
compensation of cyclotorsional errors as well as pupil
centroid shift between the wavefront measurement
and the laser ablation. In fact, studies show that
cyclotorsion occurs in most patients, with 2.2° and
4.3° on average, and 10% with more than 7°. A
simulation of a cyclotorsion of about 5° in astigmatism
of just 1 D shows significant deterioration of image
quality (Fig. 1). Deterioration starts at about 2°, and
at 5° of misalignment a significant change occurs.
Therefore, compensation for cyclotorsional errors
does indeed matter clinically. The compensation is
done using iris registration on the VISX system. Two
pictures are taken, one at the WaveScan aberrometer
and one at the laser. The software identifies iris
details and matches the images. Then the laser rota-
tes the axis of treatment to compensate for the offset.
Even more important is the compensation of the
pupil centroid shift, which occurs when the pupil size
changes. Usually, the center of a dilated pupil will
move nasally and inferiorly when the pupil constricts.
Without compensation, the laser treatment would be
decentered, which causes induced coma. As little as
0.25 mm of decentration, which is the average amount
of pupil centroid shift we found, can cause significant
218 Multifocal IOLs
coma, according to Douglas D. Koch, MD, Houston,
TX, who presented his data at the AAO 2005. So
compensation for pupil centroid shift is even more
important than previously anticipated.
Limits of Customized Ablations
Obviously a customized ablation is not the only way
to perform laser vision correction after implantation
of a multifocal IOL. In fact, only certain multifocal
IOLs can be measured reliably using current
aberrometry. The WaveScan aberrometer can reliably
measure refraction and higher-order aberrations of a
Tecnis multifocal IOL as has been shown in a model
eye study. However, the WaveScan cannot measure
the wavefront in a model eye with the ReZoom
multifocal IOL as spot distortion occurs. A
customized laser vision correction is therefore not
recommended in eyes with a ReZoom multifocal IOL.
In addition, data on custom laser correction using the
Visx CustomVue system are still limited, and care
must be taken if wavefront refraction and manifest
refraction do not match. I recommend using
customized laser vision correction only if manifest
and wavefront refraction do not differ by more than
0.5 D. If measurements do not match, conventional
laser vision correction should be used in multifocal
IOLs. If in doubt, I recommend the use of a PreVue
lens to demonstrate the effect of the customized
ablation to the patient.
When Should Laser Vision
Correction be Performed?
Multifocal IOLs require a certain time for
neuroadaptation, wound healing causes some
astigmatism changes, and wound stability is a
concern whenever a clear corneal or posterior limbal
incision has been done. Therefore, laser vision
correction should be performed after a certain period
only. I usually wait three months to perform LASIK
after the multifocal IOL implantation. I use a
posterior limbal incision as my standard technique
to perform lens surgery. A longer wait may be
required when a clear corneal incision is used. If
wound stability is a concern, surface ablation can be
performed, too.
In patients with high corneal astigmatism
preoperatively, I use a different approach. I define
“high” as more than 2 D of corneal astigmatism (not
manifest or total astigmatism, as the lens will be
removed!). In these patients, I anticipate a need for
laser vision correction in most cases. I will therefore
create a corneal flap using my IntraLase femtosecond
laser immediately prior to the lens exchange or
cataract surgery, without lifting the flap. The
advantage of the IntraLase is that the flap can be
created without the need to lift it. After the flap
creation, lens surgery is performed and a multifocal
IOL is implanted. About four weeks after the IOL
implantation, the flap is lifted and laser vision
correction is performed as described above.
CONCLUSION
Overall, the success rate of multifocal IOLs can be
greatly enhanced by offering them as a package with
laser vision correction, ideally a wavefront-guided
LASIK. Without performing LASIK, 80-90% of
patients may achieve spectacle independence.
However, with LASIK success rates are over 95%.
Therefore, adding multifocal IOLs to your practice
should also include the potential for LASIK
enhancements provided either by the surgeon or a
partnering LASIK centre. When this approach is
presented to patients as a package from the initial
consultation, they understand and accept it as the best
way to get the visual result they desire.
 Phaco-Ersatz: Will it be there Tomorrow? 221

26
Phaco-Ersatz: Will it be
there Tomorrow?

Oliver Stachs, Rudolf F Guthoff

INTRODUCTION enable far and near vision without glasses. However,

Replacing the lens of a human eye by an artificial optical or mechanical concepts have a limited
Intraocular Lens, either during cataract surgery or accommodative ability. So far, the results of scleral
for other medical reasons, restores clear vision. or corneal techniques are doubtful. Concepts focusing
Approximately 14 million IOL units were sold on improved artificial lens materials are most
globally in 2005, producing 1.28 billion USD in total promising, but are still at a very early experimental
stage.
revenues. An aging global population, newly
developed IOLs, and growing worldwide access to
HUMAN ACCOMMODATION AND PRESBYOPIA
advanced medical technology are expected to
produce a very high annual growth rate over the Accommodation is a dynamic process, defined as
next years. an optical change of the power of the eye1,2 originally
Efforts are being made on several fronts to described by Helmholtz in 1853 A (Fig. 1). In the
develop even more advanced IOLs that mimic the
natural lens, are injectable through a tiny incision,
and restore accommodation. Today, technological
developments with regard to phakic, accommo-
dative, multifocal, adjustable and toric IOLs are
being pursued along different tracks. The most
immediate beneficiaries of new IOL designs are
cataract patients seeking improved vision, thus
eliminating the need to wear glasses. If these future
IOLs perform according to expectation, cataract
patients will experience significantly improved visual Fig. 1: Profile drawing of the lens in the accommodated and
the unaccommodated state, respectively, according to
acuity and will be able to live without glasses. In
Helmholtz’s hypothesis described in 1853
order to surgically restore accommodation and to
treat presbyopia, the process of accommodation and AIch halte es deshalb für wahrscheinlich, dass die Linse ihre Gestalt
its loss in the aging eye must be understood. This is ändert, und beim Sehen in die Nähe nach vorn convexer wird. [I
one objective of this contribution. therefore consider it likely that the lens changes its shape, becoming
One of the greatest challenges of ophthalmology, more convex in front during near vision.] Bericht über die zur
Bekanntmachung geeigneten Verhandlungen der Königl. Preus.
especially of cataract surgery, is the restoration of
Akademie der Wissenschaften zu Berlin [report on the publishable
accommodation in presbyopic eyes. There have been arguments of the Royal Prussian Academy of Sciences in Berlin] in
various attempts at solving this problem in order to the month of February, 1853
222 Multifocal IOLs

meantime, this theory has been confirmed by several

authors.4-6
In a phakic eye of a young subject, contraction of
the ciliary muscle moves the apex of the ciliary body
to release at-rest zonular tension around the lens
equator. Configuration changes of the ciliary muscle
are shown. These changes, together with the elastic
lens capsule, allow the lens to assume the
accommodative state.2
During accommodation, the lens shows a
decrease in equatorial diameter and an increase in
axial thickness, associated with an anterior and
posterior increase of the lens curvature. 7,8 These
changes in lens thickness decrease the anterior
chamber depth while increasing the anterior segment
length.9 The optical power of the eye increases with
the increasing lens surface curvature (Fig. 2).
Presbyopia is loss of accommodation with age,
an effect that has been attributed to alterations of
the posterior attachment of the ciliary body, 10,11
Young’s modulus,12,13 and the geometry of the lens,14
respectively. Lens hardening is the generally accepted
key factor of age-related loss of accommodation.

CONCEPTS OF RESTORING ACCOMMODATION

During cataract surgery, an intraocular lens is
implanted in the capsular bag. Despite excellent
restoration of visual acuity and biocompatibility, no
accommodation is detected in pseudophakic eyes, as
the IOL optics change neither shape nor position in
any way.
To restore accommodation in the human eye, the
physiology of the accommodative structures must
remain viable. Any residual activity needs to be
utilized in order to design an implant to restore the
accommodative ability.
Various attempts have been made to solve or
bypass this problem:
• Monovision to correct presbyopia15
• Multifocal vision to correct presbyopia (lens-
based,16,17 corneal18)
• Laser treatment of the lens contents19,20
• Scleral expansion procedures21,22
• Accommodative intraocular lenses23
– Single optic IOLs with flexible haptic support
– Dual optic IOLs
– Deformable accommodating IOLs
– Cubic optical elements (Alvarez principle)24
Figs 2A and B: Changes in anterior chamber depth and
posterior lens pole position (measured by partial coherence
interferometry) in relation to the refractive changes (measured
with a Hartinger coincidence refractometer) of a 27-year-old
subject (pharmacologically induced accommodation with 2%
pilocarpine, negative values represent an anterior shift).
Unpublished data
• Refilling the empty lens capsule (lens refilling,
Phako-ersatz)25-29
• Mechatronic concepts
These different attempts have met with varying
success. Monovision is not physiological. Optical or
mechanical concepts afford limited accommodative
ability. Scleral or corneal concepts show doubtful
results. Artificial lens material concepts are the most
promising strategies, but they are still at a very early
experimental stage.

All in all, todays’ ophthalmologists have very
limited means of helping their patients live without
reading glasses. The list includes monovision,
multifocality, and IOLs with flexible haptic support.
Some techniques are associated with certain side
effects in terms of contrast sensitivity. It is still
impossible with these techniques to offer patients
complete restoration of the accommodative eye
function.
Injectable Accommodative Lenses
The concept of replacing the stiff presbyopic lens
with a material imitating the young crystalline lens
is not a new one. A variety of pertinent publications
are available.
In general, although each of the investigators
(Table 1) successfully elucidated many of the ideal
parameters, some major problems still remain:
• Creating a microcapsulorhexis: An injectable gel lens
requires a robust capsule and therefore a very
small capsulorhexis (< 2 mm), which necessitates
innovative micro-instrumentation as well as
extensive surgical training.
• Phacoemulsification through microcapsulorhexis:
Performing phacoemulsification through such a
tiny capsulorhexis presents a significant challenge.
Although bimanual microincision techniques
allow increasingly smaller incisions, performing
the entire procedure through a sub 1 mm hole in
the capsule requires an innovative approach.
Table 1: Fundamental studies regarding lens refilling procedures
Study Specimens
Kessler28 Cadaver and rabbit
Agarwal30 - Silicone elastomer
Parel31 Cadaver, cat, rabbit, monkey
Nishi32-34 Rabbit
Stachs35 Rabbit
Hettlich27,36 Rabbit
Haefliger38 Monkey
Koopmans 39 Monkey
Ravi40,41 Porcine cadaver
de Groot42 In vitro
Han43 In vitro, rabbit
Phaco-Ersatz: Will it be there Tomorrow? 223
• Sealing the microcapsulorhexis: Sealing the
microcapsulorhexis to prevent leakage from the
bag is a challenge.
• Polymer biocompatibility: Whatever gel material is
selected, its biocompatibility is still essential and
must be reliably established. Many of the materials
used in current IOL designs have passed years of
biocompatibility testing. This was accomplished
by relying on materials that are used in other parts
of the body as well; however, given the unique
requirements of injectable gels, this is unlikely.
• Lens capsular volume variability: Lens capsular
volumes vary widely among patients. In theory,
only the optimum amount of gel allows the
necessary changes in lens curvature. Controlling
the injection of a gel with this much precision is a
significant challenge.
• Polymer refraction: Achieving the desired refraction
is not so easy, either. IOL lens power requirements
vary widely among patients and determining the
optimal amount of gel required to achieve the
required power correction is a challenge.
• Preventing PCO: Finding a way to prevent PCO or
ACO presents another significant challenge. With
conventional IOLs, an Nd:YAG laser pulse can
eliminate opacification; however, an injectable gel
material would leak from the opening created with
a laser.
The major problem seems to be PCO development
because of the lens epithelial cells found on the inside
of the capsular bag after phacoemulsification.
Refilling material
Immersion oil, silicone fluids, silastics
Divinylmethylcyclosiloxane
Polymethyldisiloxane liquids
Polymer silicone material
Monomer mixture (photopolymerization)
Silicone polymer gel
Polymer silicone material
Polyethelene glycol-based hydrogels; acrylamide and
bisacryloylhistamine-based hydrogels
Isocyanate-crosslinked hydrogels derived from polyalcohols
Poloxamer hydrogel
224 Multifocal IOLs
Opacification of the posterior capsule caused by
postoperative proliferation of cells in the capsular bag
remains the most frequent complication of cataract-
intraocular lens surgery.44,45 In addition to classic
posterior capsular opacification (PCO, secondary
cataract, after cataract), postoperative lens epithelial
cell proliferation is also involved in the pathogenesis
of anterior capsular opacification/fibrosis (ACO) as
well as interlenticular opacification (ILO). 46-48
Secondary cataract has been recognized since the
origin of extracapsular cataract surgery and was
noted by Ridley in conjunction with his very first
IOL implantations. 49,50 This phenomenon was
particularly common and severe in the early days of
IOL surgery, when the importance of cortical
cleanup was less appreciated. Through the 1980s and
early 1990s, the incidence of PCO ranged between
25 and 50%.51,52 PCO is a major problem in pediatric
cataract surgery, where it occurs in almost 100% of
all cases.53
One of the crowning achievements of modern
cataract surgery is the gradual, almost unnoticed
decrease of this complication. The literature at present
shows that with modern techniques and IOLs, the
expected rate of PCO and the subsequent Nd: YAG
laser posterior capsulotomy rate is now less than 10%.
There are a number of surgery-related and IOL-
related factors to prevent posterior capsular
opacification. Surgical factors include hydro-
dissection-enhanced cortical cleanup,54 in-the-bag
(capsular) fixation,55 and the capsulorhexis edge on
the IOL surface. Besides, there are basically three IOL-
related factors to reduce PCO IOL biocompatibility,
maximum IOL optic-posterior capsular contact,56,57
and the barrier effect of the IOL Optic.58,59 But none
of these techniques are suitable for lens refilling.
Another approach to prevent PCO involves the
intraocular application of pharmacological agents.60,61
For the 1980s, numerous investigators like Weller
and Rieck62,63 examined in cell culture studies the
potential of pharmacological substances in order to
successfully prevent LECs from proliferating and
migrating. Pharmacologic agents that have been
investigated include cytostatic drugs, such as 5-
Fluorouracil, 64,65 Daunomycin, 62 Colchicine,
Doxorubicin,66 Mitomycin C, 64,67 Methotrexate, 68
anti-inflammatory substances, such as Dexa-
methasone 69 and Diclofenac, 70 calcium-channel
blockers, such as Mibefradil71 and immunological
agents, such as Cyclosporine A.72 In addition adhe-
sion inhibitors73 and osmotic effective solutions74
were tested. In several studies different drug
delivery systems75-78 were investigated in order to
provide a longer and more effective impact on LECs.
The goal of our studies was to develop an ex vivo
model by utilizing capsular rhexis specimens obtained
during standard cataract surgery that can be tested
for the ablation of LECs from the basal membrane.
Since capsular rhexis specimens contain a LEC layer
on its natural substrate, the basal membrane, an
effective cell ablation method established in the ex
vivo model should also be effective in vivo.
To test the suitability of the model to differentiate
drug effects on LECs of the capsular bag three
pharmacological compounds known for their
antiproliferative activity, Disulfiram, Methotrexate
and Actinomycin D were tested for their effect on LEC
ablation. Disulfiram, chemically tetraethylthiur-
amdisulfide (TETD), and its primary metabolite
diethyldithiocarbamate are known to have in vitro
antiproliferative effects on tumor cells, and inhibit
several enzymes and cell proteins by formation of a
metal complex or by reaction with functional
sulfhydryl-groups. In addition it has been shown that
a topical ocular drug delivery system containing
TETD has anticataract effects in vivo on selenite-
treated rats.
Methotrexate (MTX) is an antimetabolite drug
used in treatment of cancer and autoimmune diseases.
It acts by inhibiting the metabolism of folic acid. Based
on research efforts in cancer chemotherapy, Hansen
and co-workers79 have found that a conjugate of MTX
with an antibody specific for basement membrane
collagen in the lens capsule is an effective inhibitor of
LEC outgrowth in cell culture.
Actinomycin is any of a class of polypeptide
antibiotics isolated from soil bacteria of the genus
Streptomyces. As chemotherapeutic drug Actino-
mycin D (AM) intercalates into DNA, thereby
interfering with the action of enzymes engaged in
replication and transcription. Therefore it could be
also an effective inhibitor of LEC viability.
Cultured capsular rhexis specimens from
standard cataract surgery were used for these
experiments. For the evaluation of the cell inhibitory
and detaching potential of drugs the culture medium

was replaced by different drug solutions. The
specimens were incubated with these solutions for
5 minutes. The model drugs Disulfiram,
Methotrexate and Actinomycin D were dissolved in
pure water or were embedded in the hyaluronic acid
(HealonTM, AMO) in a drug concentration of 10μmol/
l. After drug treatment the total number of residual
cells on the surfaces of capsular rhexis specimens
was assessed by use of microscopic methods. The
residual viable and dead lens epithelial cells were
differentiated by use of the Live-dead assay.
Quantification of the lens epithelial cells was
facilitated by staining with Hoechst-dye.
In summary, an ex vivo model was established
which allows for the differentiation of drug action on
lens epithelial cell ablation from the basal membrane.
To estimate the effectiveness of drugs it was necessary
to determine the cell numbers of untreated capsular
rhexis specimens. The Live-dead assay on untreated
capsular rhexis specimens has shown 1361 +/- 482
viable cells/mm2. The treatment with Disulfiram,
Methotrexate or Actinomycin D reduced the number
of viable cells on capsular rhexis specimens
drastically, because it ranges between 0.44 +/- 0.53
Figs 3A to F: Rabbit eye after lens refilling and capsular treatment with pure water,
1 month respectively 3 months postoperatively. Unpublished data
Phaco-Ersatz: Will it be there Tomorrow? 225
% (6.0 +/- 7.3 cells/mm2) for Disulfiram, 0.27 +/-
0.50 % (3.7 +/- 6.9 cells/mm2) for Methotrexate and
0.07 +/- 0.19 % (0.1 +/- 0.27 cells/mm 2 ) for
Actinomycin D. Of the three tested drugs
Actinomycin D was slightly more potent in cell
ablation than Disulfiram and Methotrexate.
Pure water is very effective with regard to in
vitro LEC cyclolysis and ablation. However, the in
vivo effectivity of pure water is known to be
compromised by the diffusion of the body liquid,
which is confirmed by our in vivo observations of
rabbit eyes. Figure 3 shows rabbit eyes after lens
refilling and pure water treatment (5 min) of the
empty capsular bag in a study performed in Rostock.
One month after surgery, the eyes were still clear,
later to develop PCO three months postoperatively.
Based on the findings in several series of animal
experiments, the empty capsular bag was exposed to
a toxic Healon mixture for 5 min. After being 5 min
treated with a viscoelastic solution (HealonTM, AMO)
containing Actinomycin-D, rabbit eyes—during the
follow-up period of more than 16 months—show
basically no PCO development (Fig. 4). PCO and ACO
are absent in these operated eyes. No leakage
226 Multifocal IOLs

Figs 4A to D: Slit-lamp photographs of an eye with a refilled lens treated for 5 min with viscoelastic solution (HealonTM, AMO)
containing Actinomycin-D, obtained 9 (A and B) respectively 16 (C and D) months after surgery. No in vivo leakage problems
were observed. PCO and ACO were absent in all operated eyes. Unpublished data

problems were observed in vivo. Anterior chamber

Fig. 5: Anterior chamber depth (ACD) and lens thickness (LT)
of the refilled rabbit lenses during a follow-up period of up to
80 weeks. Unpublished data
depth and lens thickness are shown in Figure 5.
Another highly effective secondary cataract
prevention technique involves treatment with a
viscoelastic solution containing Methotrexate (MTX)
and Actinomycin-D (AD). Upto 15 months after
surgery, none of the eyes treated with an MTX +
AD/Healon mixture show PCO or ACO develop-
ment. There is a slight PCO in the rhexis and
equatorial area (Fig. 6). Quite the reverse is true –
within 6 weeks after surgery, rabbit eyes without
capsular bag treatment develop considerable, if not
massive PCO.
If the capsular bag is to be treated with a toxic
agent, it is important to protect the corneal endo-
thelium. In our rabbit experiments we used a
viscoelastic agent (Healon TM, AMO) as a carrier
substance. As an indicator for a safe capsular bag
treatment was investigated the corneal endothelium
 Phaco-Ersatz: Will it be there Tomorrow? 227

Figs 6A and B: Rabbit eye after lens refilling and capsular treatment with a viscoelastic solution containing
D,L-Methotrexate (MTX) and Actinomycin-D (AD). The images were obtained 15 months postoperatively
(A) respectively 2 years postoperatively (B). Unpublished data

Figs 7A and B: Confocal microscopic images of the endothelium with the natural lens; the refilled lens was
imaged 20 months after surgery. There is no difference with regard to the shape, the number, and the
distribution of corneal endothelial cells. Unpublished data

using an in house developed in vivo confocal micros-
copic technique.80 Figure 7 shows the endothelium
in a natural rabbit eye respectively 20 months after
lens refilling and MTX + AD tox treatment. Neither
the shape nor the number and distribution of corneal
endothelial cells had changed in any way
preoperatively and postoperatively.
In general, rabbit eyes—without capsular bag
treatment—are prone to considerable PCO develop-
ment shortly after cataract surgery. These trials,
performed with viscoelastic solution containing
Actinomycin-D or Actinomycin-D and D,L-
Methotrexate, were a good starting point for further
mammal experiments. Further investigations
involving non-human primates are needed to validate
these results.
CONCLUSION
These results suggest that accommodation can be
restored and that new IOL designs, lens refilling
techniques, or even entirely different approaches (e.g.
mechatronic concepts, cubic optic elements) may
improve lens performance and achieve clinical
success in the future. We were able to demonstrate
228 Multifocal IOLs
that the ciliary muscle remains active even at more
advanced age. The results obtained by simulating
accommodation based on our current knowledge of
the pertinent biomechanical properties are compatible
with Helmholtz’ theory of accommodation, and they
correspond to the empirical observations. We were
also able to demonstrate that mechanical concepts
based on the axial shift principle have very limited
accommodative ability. This is consistent with the
meta-analysis of peer-reviewed publications about
these lenses. Thus, successful new concepts can only
be developed with a thorough biomechanical
understanding of all accommodative structures and
processes as well as presbyopia. Sine quanon for all
concepts is the control of the PCO problem.
Obviously, although subjective clinical results are
important, objective methods really are essential to
evaluate new design developments. A variety of
instruments are available for objective accommo-
dation measurements as well as mechanical
performance.
To summarize matters, our study gave rise to the
following conclusions:
• In order to surgically restore accommodation so
as to treat presbyopia, we need to fully understand
the loss of accommodation in the aging eye.
• When monitoring ciliary muscle activity, we need
to differentiate between ciliary muscle sections
with and without ciliary processes, respectively.
• During pharmacologically stimulated accommo-
dation, the ciliary muscle moves centripetally in
the direction of the lens, covering a distance
between 0.04 and 0.26 mm, depending on the age
and the subject.
• Accommodative ciliary muscle activity was
observed even in presbyopic eyes, which goes to
show that ciliary muscle activity is not the limiting
factor in restoring accommodation.
• Attempts at restoring accommodation should be
based on Helmholtz’ theory of accommodation.
• The physiological magnitude of the refractive
power changes can be explained by mathematical
simulation according to Helmholtz’ theory of
accommodation.
• Artificial devices to simulate accommodation,
including ocular tissue relevant for accommo-
dation, may help us understand and evaluate new
accommodative implants.
• To date, mechanical IOL concepts for so-called
accommodative lenses have limited accommo-
dative ability.
• New artificial lens materials (for lens refilling) are
promising but are still at an early experimental
stage.
• The capsular bag can be refilled with an artificial
lens material, using a small opening. The capsular
opacification problem, however, needs to be
solved.
• In order to understand whether accommodation
is restored by an artificial device, we need to
demonstrate objectively that the eye undergoes an
active change in optical refracting power during
accommodation.
• In order to distinguish accommodation from
pseudoaccommodation, we need objective
methods to measure optical changes in refractive
power or physical changes in the lens.
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 Index
A Clinical results of MICS multifocal IOLs 204 Functional organization of the visual
clinical data 204 system 38
Accommodating IOL (AIOL) 108
clinical outcomes of AcriLISA 366D
Accommodative lens refilling 12
205
Accuracy of IOL power calculation 102 H
intraocular optical quality 205
Acri.LISA 85
AcriLISA “in vivo” optical quality Higher order aberrations 206
AcrySof ReSTOR 87
studies 205 Human accommodation and presbyopia
Amount of refilling 14
Combining different types of multifocal 221
Anterior aspheric optic surface of the tecnis
IOLs 72
multifocal IOL (SEM) 71
Concepts of restoring accommodation
Anterior chamber multifocal IOL 72 I
222
Aqualase 152 Imaging quality of LISA (366 D) with
Confocal microscopic images 227
Congenital cataract 149 optimized optic 206
B Impact of binocularity on near VA 85
Current offering of multifocal IOLs 65
Bilateral refractive lens exchange with the Customizing multifocal IOLs 163 Importance of managing expectations 60
diffractive multifocal tecnis Cystoid macular edema 118 Importance of reading speed 28
ZM900 IOL 192 Improvement of visual of function with
patients and methods 193 D training 47
IOL power calculation 193 3D-eye office program 58 assessment of OVA 48
measurements 194 Deformable optic IOLs 79 materials and methods 48
patients selection 193 Diffractive multifocal IOLs 69 purpose 47
statistical analysis 194 combination refractive-diffractive results 48
surgical technique 194 multifocal IOLs 71 training method 48
results 193, 194 ReSTOR clinical results 69 Injector system for synchrony IOL 135
accuracy of IOL power calculation Dual-optic accommodative IOLs 77 International standards visual acuity 20
194 Intraocular lens implantation in children
patient satisfaction 195 E 156
preoperative characteristics 194 choice of the lens 156
Estimated IOL position (ELP) 101
Bilateral ReZoom implantations 141 contraindication 158
Evolution of usage of multifocal IOLs 73
Bio ComFold 43S 72 postoperative follow-up 159
Exclusion criteria 178
preoperative points 159
eye disease 178
secondary implantation 158
C macular disease 178
surgical techniques 159
moderate or severe dry eye 178
Capsular opacification 14 IOL calculation for multifocal IOLs 93
moderate to deep amblyopia 178
Capsulorhexis 186 calculations 95
Cataract light scatter 59 material and methods 93
F
Cataract or lens surgery 210 patient data 93
capsulorhexis 210 Female satisfaction after implantation 167 results 95
hydrodelineation 211 First experiences with the Rayner aspheric, IOL power formulas 101
hydrodissection 211 toric, multifocal intraocular regression formulas 101
incision 210 lens (M-flex-T) 138 theoretical formulas 101
Cataract POV 59 patients and methods 138 IOL power in aphakic eye 106
Characteristics of 3 multifocal intraocular results 139 IOL power in phakia and piggy-back IOL
lenses 84 Fix postoperative refractive surprises 116 107
Clear corneas 117 Flash-lag effect 42 piggy-back IOL power 107
Clear lens extraction 180 Freiburg visual acuity test 23 IOLs for refractive lens exchange 75
234 Multifocal IOLs

Iris registration 217 preoperative testing 186 Preoperative astigmatism 186

limits of customized ablations 218
Irrigation aspiration 153
J surgical technique 186
Jaeger charts 19
L Radner reading charts 29
Laser enhancement after multifocal IOL
implantation 215
lens surgery 215
customized laser vision correction
216
mix and match 216
patient selection 216
Lens characteristics and differences 172
diffractive lenses 172
regarding other diffractive lenses 173
regarding other diffractive
multifocal lenses 173
tecnis multifocal 172
Lens stretching study 13
Lenses that move in the eye 76
LiquiLens 82
M multifocal IOLs 3
Male satisfaction after ReZoom
implantation 167
Medennium smart IOL 81
Microincision cataract surgery (MICS) 201
advantages 202
MICS MF IOLs: AcriLisa 203
Mixing and matching customized approach
Tecnis-ReZoom 171
improving intermediate vision 171
preoperative tests 172
Mixing and matching IOLs 126
options 127
outcomes 128
Motion perception and dynamic vision 40
Multifocal IOLs 65
Multifocal IOLs in children 148
Multifocal IOLs the approach 183
enhancements–complications–lens
exchange 187
implantation technique tecnis or
ReZoom 187
patient expectations 185
product description: tecnis –reZoom Presbyopic population 18
lens 183 Primate study 15
ReZoom multifocal IOL 184 Pupil size 31
Pursuit analysis 43
Multifocal lens and dynamic vision 41
R
N
Near vision 31 Reading acuity and reading speed 31
New generation formulas 103 Reading acuity and reading speed after
Haigis formula 105 cataract surgery 29
Hoffer Q formula 104 Reading speed measurement 35
Holladay formulas 104 Reduce preexisting corneal astigmatism 116
Lin’s formula 106 Refractive lens exchange 188
Olson formula 105 patients and methods 188
SRK formula 104 IOL power calculation/surgical
New innovative technologies 80 technique 188
New lens refilling material 13 measurements and anaylsis 188
results 189
O Refractive multifocal IOLs 68
clinical results 69
Oculocardiac reflex 150
ReZoom clinical results 68
Opacification of the posterior capsule
Refractive multifocal lenses 173
224
ReZoom 173
Optical principles 3
Refractive surgery 180
diffractive MOILS 4
Residual refractive error 31
ReZoom multifocal IOL 68
refractive MOILS 3
Right intraocular lens 118
Optical properties of the ReZoom 142
S
P
Screening pursuit test 44
Patient administration using software
Signal detection theory 23
technology 60
Snellen acuity 18
3D-eye advisor 60
Soft irrigation and aspiration 117
3D-eye home 60
Surgical approach according to sex 169
Pediatric cataract 180
Surgical procedure of lens refilling 16
Perioperative routine and selection of
anesthetic agents 150
T
Personal experiences with the single optic
1 CU and the synchrony dual Tecnis multifocal IOL 70
optic accommodative IOLs Tecnis ZM900 70
133 Testing optical performance on an optical
Phaco-Ersatz 212 bench 6
Physician’s attitude toward a dissatisfied
patient 181 U
Piggy-back IOL- power (P) formulas 108 U/S-phaco emulsification 211
Posterior rhexis and vitrectomy 153 M-IOL implantation 212
Postoperative refractive accuracy 115 phaco Caroussel technique 211
Precise IOL calculations 115 surgical media center 212
 Index 235

Underpromise and overdeliver 118 encouragement and feedback for V

implanting premium IOLs in patients patients 125
Virtual office 60
with compromised capsular minimize complications 124
postoperative refractive status 125 Visual requirements for reading 28
support 120
accommodating intraocular lenses timeline of healing and visual
recovery 124
123 Y
premium intraocular lenses in patients
anterior capsular tears/
with prior refractive surgery Yag capsulotomy 144
radialization 121
118
posterior capsule rupture 122 intraoperative considerations 119
weak and missing zonules 122 IOL power calculation 119 Z
postoperative management of patients IOL selection 118
with presbyopic IOLs 124 postoperative management 120 Zonular tension 18